What we did was meaningful. I was drawn to start this publication because it presented an opportunity to break out of the typical crisis-driven flow and ebb of journalism about the field. Harvard wasn’t a publisher, but it was in the business of sharing knowledge, and I thought we could do for public health what Harvard Business Review does for business. I believed there was no public health without the public, and while it took some feints and half-steps to figure out what that meant for our journalism, we eventually settled on assessing every story idea with a simple question: “What would this story change?” Implicit was a corollary question: “And for whom?”

In the meantime, we relaunched the magazine as a digital publication, built out a social media presence, and launched a weekly newsletter. We co-sponsored a well-attended structural racism symposium and special issue, a series on public health data, a Public Health in Action collaboration with The Studio at the Harvard T.H. Chan School, and an event on artificial intelligence with Johns Hopkins Bloomberg’s Global Health Now. We had momentum—visitors to the site almost tripled in last year’s fourth quarter versus the prior year. Almost 15,000 people signed up for Harvard Public Health Weekly, close to 90 percent of them not connected to Harvard.

Readers ate up pieces on processed foods, the health effects of alcohol, and mental health. You also read our beautifully written and photographed narratives like the 10^th anniversary of the Flint water crisis or our look at Christian Happi’s bold aims for African science, and public health’s role in the recent Puerto Rican elections.

Our goal was to publish stories that would help improve health outcomes. That’s hard to measure in three-and-a-half years. But over 40 percent of you opened the newsletter in a typical week. In the last year, readers shared our articles more than 2 million times on social media. We’ve had at least 25 stories republished on other sites and 40 mentions in newsletters. Our stories have been cited in other publications and used in classrooms.

Public health outcomes change slowly, so it’s harder to measure real-world impact. I would love to hear from you about trying an idea you read about in HPH, or even if you just shared the idea with a colleague. Did you use an article from HPH in a class or a meeting? It would be great to hear from you at our inbox, magazine@hsph.harvard.edu. It will be live for a few more months. So will the site, and I encourage you to download articles you found useful.

The pandemic sparked a surge of public health journalism. These are the sites and newsletters I follow closely or scan regularly, and recommend to you:

• Axios Vitals
• Devex CheckUp
• The Examination
• Global Health NOW
• The Harvard Chan Studio
• KFF Health News
• MindSite News
• Public Health Watch
• The Healthiest Goldfish
• Your Local Epidemiologist
• ProPublica
• STAT Morning Rounds
• TradeOffs (podcast)

Also, the new Healthbeat is off to a promising start, focusing for now on Atlanta and New York City.

I have had a long and varied journalism career, much of it spent chronicling the vast impact of high technology. I have never done more meaningful and important work than what we were doing at Harvard Public Health. I am so thankful to the school, colleagues past and present and our fabulous advisory board, everyone who gave me informal counsel, and all the readers who reached out. I rue that we won’t be able to continue. But a wonderful thing about public health is its focus on the public. It is political with a small ‘p,’ rooted in communities.

What’s most important is that you in the public health community (and in the public) stay engaged in doing the good work you do. Keep telling your stories!

Onward,
Michael F. Fitzgerald

The post A farewell to HPH readers appeared first on Harvard Public Health Magazine.

Its biggest goal is fighting soil-borne diseases, which helps break the chronic cycle of poverty. A side benefit of avoiding disease is that it helps keep kids in school. Operating the shoe fund as a business makes it less reliant on donations. “Charity is not sustainable for lasting change,” says Courtney Cash, president of the World Shoe Fund. “We must invest in scalable market-based solutions to see true transformative social impact.”

Cash talked with Harvard Public Health’s Christina Williams about the World Shoe Fund’s goals. This interview was edited and condensed.

Harvard Public Health: What public health purpose does your idea serve?

Courtney Cash: We promote positive hygiene practice and shoe-wearing. There were a lot of different issues related to people going barefoot in contaminated soil—worms, soil-transmitted helminths, podoconiosis, jiggers [tunga penetrans], and other pathogens that would enter through the feet. So, we began to look at whether shoes would act as a natural prophylactic against disease.

HPH: Who is funding it and do you have access to capital?

Cash: One of our partners in our original pilot in Ghana was Sanford Health Systems [in Sioux Falls, South Dakota]. Denny Sanford provided catalytic funding for us to do our initial prototype and pilot. He [also] gave us the investment that allowed us to start a factory in Okasembo, Ghana.

Our regional factory in Ghana has the capacity to manufacture five million shoes per year. We have a phased expansion model that starts with a humanitarian partnership, [followed by] retail demand, a distribution center, and a micro-factory. With this plan in action, we expect to have two additional regional factories in Central and Southern Africa in the next few years.

HPH: How do you get paid for it, and who are your clients or customers?

Cash: Global health agencies, like the United States Agency for International Development (USAID), [the Gates Foundation], and CIFF [Children’s Investment Fund Foundation], become the intermediary funder to our government partners. For example, the minister of local government in Rwanda wants to use our shoes for a health and hygiene initiative — promote hygiene, promote vaccines, [tuberculosis] testing, and prenatal, malaria, and HIV screenings for moms. Together, we would go to a third party that actually funds the procurement of the shoes.

In December of this past year, we launched a retail brand of our shoe with multiple colors and have a clog and a slide that are coming out for sale in Ghana and soon in the United States. That’s our long-term sustainability [plan]. To date, we’ve sold 1.5 million pairs of shoes for humanitarian purposes.

HPH: What are your obstacles to success?

Cash: We deal with traditional obstacles to setting up your business lines, like: How do we create a business-to-consumer product in Africa? How do we create a business-to-business product? How do we sell a humanitarian cause? How do we get a third party to pay for the shoes to give away to the end user? How do we not just stay as a donation-based humanitarian organization? [In Africa] on the humanitarian [side], we’re working through implementation partners that have been doing it for years, governments that know what they’re doing. But we’re trying to set up retail and economic development in Africa, a very fragmented country-to-country market. The way we started to address that one is through co-creation and working with people on the ground on design and distribution models, [not] Americans telling the Africans what they should do. We need to bring what we can to the table, but we need to listen and learn in the African context as to the best way that we’re going to sell shoes on that continent.

Because our partnerships have all been affected by the “USAID pause,” we are focusing more on the local government partnerships and our alignment with the WHO Roadmap 2023, the U.N. Sustainable Goals, and the UNICEF WASH model we’ve incorporated into the product in our WASH&WEAR distribution model.

HPH: How do you show your value or impact?

Cash: In Sierra Leone, we [recently] distributed shoes to 10,000 girls in three days. Each girl got one year’s worth of sanitary pads and the shoes that they needed. There’s also a lot of qualitative data that we’re seeing. To give you one example out of Rwanda, kids were getting to school and saying that [their feet] don’t hurt as much. What the teachers were saying is test scores were better, attendance was better … because [kids] had proper footwear. Our randomized control trial, done in collaboration with Move Up Global, showed a 34 percent decrease of worm-infected diseases in program participants. The group’s school attendance also increased by 15 percent. So, there’s never any question about whether it’s the shoes. These shoes bring real change, and when we look at value, it really is all about the shoe.

The post Elevator Pitch: World Shoe Fund appeared first on Harvard Public Health Magazine.

“I used to have frequent headaches and a burning sensation in my toes,” says Kiplangat, now 61, of the side effects from Glucophage and other drugs he was prescribed. A colleague said his diabetic father saw tremendous improvement after switching to herbal medicine, so Kiplangat opted to give it a shot. He gradually reduced his intake of conventional medicine and started an herbal regimen, along with lifestyle changes that included healthy eating habits. After three months, his blood sugar level had fallen to a healthy range. “Once I started using herbal medicine, the pain and headaches disappeared, and now I am completely healed and okay,” he says.

Herbal remedies have been included in research into traditional medicines by the Kenya Medical Research Institute (KEMRI) for more than four decades. But 15 years ago, researchers became more intent on looking for novel compounds to help manage and treat non-communicable diseases, including diabetes. “Access to diabetes care in low- and middle-income countries is a major challenge,” says Elsa Morandat, head of policy and programme at the World Diabetes Foundation. Morandat says both the cost of treatment and the lack of proper equipment across health systems create care gaps.

The condition has been on the rise in Kenya, from 872,000 cases 10 years ago to 2.1 million people, or four percent of adults, in 2022. Between now and 2045, Africa is projected to have the highest global increase in people living with diabetes.

“Diabetes is a huge public health problem in Kenya,” says Esther Matu-Macharia, the deputy director at KEMRI’s Centre for Community Driven Research (CCDR), which focuses on improving health outcomes. (The research itself is carried out by another KEMRI unit, the Centre for Traditional Medicine and Drug Research.) Treating it is costly—even with government subsidies, on average a vial of rapid-acting insulin costs around 4,300 shillings, or U.S. $33, and a patient may need three to four vials monthly, an almost 30 billion shillings, or $230 million, annual burden on the economy. With almost 9 million Kenyans—7.8 percent of its population—living in extreme poverty, on less than the equivalent of $2.15 per day, officials estimate that 40 percent of Kenyans with diabetes, some 750,000 people, do not receive treatment.

Several years ago, Matu-Macharia investigated whether aloe, which is plentiful in Kenya, might provide a cheaper alternative to insulin. She knew traditional healers have long used aloe extracts to treat symptoms of diabetes, such as reducing blood glucose levels, and that there had been some research. She and some colleagues took extracts from the leaves of two aloe plants indigenous to Kenya (Aloe lateritia and Aloe secundiflora) and tested them on diabetic mice through injection. Her study, published in the European Journal of Medicinal Plants, found the extracts reduced blood sugar levels in the mice while also protecting pancreatic beta cells from damage. In addition, it found the phytochemicals (part of a plant’s immune system) in the extracts acted as antioxidants, which help the immune system fight chronic diseases like diabetes.

KEMRI has subsequently partnered with hundreds of traditional healers and herbalists from around the country to tap into their knowledge on the treatment of diabetes, developed and refined over generations. Herbalists focus on plant-based remedies, while healers also incorporate holistic approaches to wellbeing.

A worldwide phenomenon

KEMRI’s work fits into the World Health Organization’s multi-year effort to create standards and expand the evidence base for traditional medicine. It is an acknowledgment of the widespread use of traditional methods, especially in rural and remote areas, and also an effort to address concerns about traditional approaches. For diabetes, although some studies have suggested using both traditional and conventional medicines to manage and treat the disease, the data is most clear that traditional knowledge has a place “in the early management of diabetes,” says Ahmed Ogwell Ouma, a senior advisor at the U.N. Foundation. He says for more advanced cases traditional approaches may not be effective.

That is similar to the official line of Kenya’s Ministry of Health. “Some [traditional remedies] are effective in the treatment of diabetes but it should be noted that these remedies do not cure diabetes,” says Pauline Duya, head of the Ministry’s Division of Traditional and Alternative Medicine. She says patients ought to be cautious in using traditional herbs.

The much lower cost of traditional treatments is one reason why KEMRI is pursuing its research, says Matu-Macharia. Plus, she says, in many parts of the country traditional healers “are the people who are managing patients.” Recruiting healers to work with KEMRI’s research team has had hurdles, she says, such as fear that KEMRI might take what it learns from them and use it to design commercial treatments that could replace their offerings. KEMRI has developed steps to ensure that information learned from the healers is protected and to communicate this clearly to the healers. “We don’t want them to feel like they are losing the knowledge to us,” says Matu-Macharia.

In fact, KEMRI says working with it brings benefits, such as confirming that remedies are effective and safe, and offering suggestions on how to improve individual remedies. All of these should improve the trade for the healers. KEMRI does not give a seal of approval for products that perform well in tests it conducts. Healers and herbalists have to ask the Pharmacy and Poisons Board (PPB), which regulates drugs in the country, to register their products. The PPB conducts more tests and analysis. Both also need also need a license from Kenya’s Department of Culture and Heritage.

One healer who has partnered with KEMRI is Munyiri Kahiu, a certified naturopath with 25 years of experience. Kahiu says he has used herbal remedies to successfully treat about 20 patients at different stages of diabetes. He also gives them customized diet and exercise programs. Kahiu says for the three-month treatment, his clients pay on average about 13,000 shillings ($100), similar to a month’s course of insulin. KEMRI validated his treatment as safe and effective.

The missing piece: a policy framework

KEMRI has developed research protocols to establish the effectiveness, safety, and quality of traditional remedies for diabetes, but KEMRI lacks the funding and legal frameworks to make them widely available. “The communities are using them now, but we cannot scale them up to commercializable products,” says Matu-Macharia. Despite the rise in cases, across Africa only one percent of health expenditure goes to diabetes care, the lowest investment rate in the world.

Nevertheless, some healers in Kenya have been able to commercialize their treatments.

When Fridah Muthomi was diagnosed with Type 2 diabetes, she found the cost of insulin and hospital check-ups too costly. In part, this was because she did not have a refrigerator and had to pay for cotton wool and surgical spirits to try to keep the insulin cold.

Her father, Moses Muthomi, is an herbalist in Nairobi. In 2015, he obtained approval from the Department of Culture and Heritage for a diabetes treatment he had researched and tested with help from Kenyatta University. Five years later, he expanded his work on herbal remedies for both communicable and non-communicable diseases, working with the University of Eldoret (both institutions are KEMRI partners). Muthomi has developed five herbal remedies, that address the effects of diabetes on the endocrine system and glucagon levels.

The products cost between 3,900 shillings ($30) and 10,060 shillings ($78) for a 48-day course of treatment. “I have so far successfully treated around 100 people who had diabetes,” says Moses Muthomi, including his daughter. She was able to stop using insulin two years ago.

Traditional healers like Muthomi say that once they get their products validated and go through the other approval processes to sell them, policy gaps are their biggest challenge. In Kenya, conventional doctors are only trained in Western medicine—and without formal government policies, doctors do not have the capacity to prescribe traditional medicines. Matu-Macharia agrees that Kenya lacks a framework for integrating traditional remedies into its health policies. “Even when we come up with products from the laboratory, it is not possible to integrate them because we don’t have legal frameworks in place,” she says. She is optimistic that the Ministry of Health, after 30 years, is close to having updated policy recommendations not only for diabetes treatment but for other conditions too. Duya cautions, though, that this is “still work in progress.”

The U.N. Foundation’s Ouma says he is hopeful Kenya will put forth regulations incorporating traditional knowledge, as it would help address public health safety concerns and boost access to treatment. Kiplangat, the former public health official, says his experience has made him wish that the policy framework would be updated so traditional approaches could be part of the public health toolkit. “Conventional medicine was not assisting me,” he says. “I hope that more people could turn to herbal medicine to manage their condition.”

The post Can traditional medicine help solve Kenya’s diabetes crisis? appeared first on Harvard Public Health Magazine.

Vawai’s older daughter, Adama, was a university student in the capital city of Freetown and shared her sister’s plight on Facebook. A nurse collaborating with Lifeline Nehemiah Projects happened to read the Facebook post and coordinated a blood donation for Vawai’s two-year-old.

Vawai’s daughter survived because a local donor was given an incentive—food and transportation—to donate blood. Blood donations save lives, but using incentives for them is controversial; even the Vawai family initially disliked the idea.  

The World Health Organization advocates for 100 percent voluntary, non-remunerated blood donation—a position that was more defensible in the 1970s, before widespread screening for bloodborne diseases like hepatitis. Today, two-thirds of the world face shortages of blood and blood products, leading to many preventable deaths, especially among women and children. More than 80 percent of the world’s population has access to only 20 percent of the global blood supply. These global inequities in blood and blood product supplies are unacceptable.

Africa, in particular, faces a disproportionate demand for blood and blood products. The continent relies heavily on family-based donation, which is not sustainable. Policies about blood supply in Africa, meanwhile, are generally based on research generated outside the continent—and in that research field, the idea of addressing blood shortages in Africa by providing adequate incentives and compensation to blood donors is met with skepticism.

We are conducting research with nonprofit organizations such as Lifeline Nehemiah Projects and with government agencies in West Africa, and shortly we will begin field experiments, to study whether non-cash incentives increase blood donation. 

While it is admirable for countries to strive for self-sufficiency in blood donations, the idea may not always be feasible, especially in smaller or resource-poor nations. In times of crisis—due to food insecurity, natural disasters, or health emergencies—many countries need external help to sustain their blood supply. The need for help from abroad will only become more urgent as the frequency and severity of such crises continue to rise.

The misalignment between blood supply and demand is especially acute in low-income countries, where the demand for blood is high due to disease burdens, traumatic injuries, and medical conditions that require transfusions. Blood shortages in these regions are also driven by factors such as a higher prevalence of sickle cell anemia and bloodborne pathogens. And yet problems such as poor nutrition limit people’s ability to donate blood voluntarily.

The United States pays donors for plasma—and exports it to countries that do not pay, and have not realized self-sufficiency in plasma supply, such as Australia, the United Kingdom, and the Netherlands. The U.S. generates billions of dollars from these sales—in a market that low-income countries cannot participate in. 

This inequity should not continue. Low-income countries should be able to obtain these supplies when needed, at a fraction of current market prices, as with HIV drugs. African countries should also be allowed to share safe blood resources with each other. 

Blood donation should not rely solely on charity but also on empowering individuals and communities to meet their own needs. In Sierra Leone, for instance, humanitarian organizations provide food and transportation to blood banks, to encourage blood donations. These incentives have significantly increased donation rates, though blood banks sometimes struggle with supply shortages, such as blood bags and needles.

Local health authorities worry about the sustainability of a safe blood stock, if or when humanitarian organizations stop providing such incentives. But the truth is that when blood supply is low, a shadow economy of paid blood donations emerges outside of hospitals, sometimes facilitated by hospital staff. 

More research is needed to identify the most effective incentives for increasing blood donations in Africa and other resource-limited settings. This research should be driven by local communities and health care workers, ensuring that policies are informed by the needs and realities of these regions. It should be led by people within these settings, so that their voices are heard, understood, and respected.

Image: antoniotruzzi / Adobe Stock

The post To meet demand, blood donation should not rely solely on volunteers appeared first on Harvard Public Health Magazine.

That is the shorthand for an ambitious goal: By 2025, ninety-five percent of people in the world who are living with HIV should know their status; ninety-five percent of those people should be enrolled in anti-retroviral treatment; and ninety-five percent of those enrolled should achieve viral suppression, which means the virus is undetectable.

The targets were adopted by UN member states in 2021 to create momentum and milestones for ending the global AIDS crisis by 2030—which is, remarkably, a goal within reach. Because it is virtually impossible for people with undetectable levels of HIV to transmit the virus, reaching those targets would, effectively, end the transmission of the disease.

UNAIDS actually introduced its first targets for ending to the epidemic a decade ago. Those goals were lower—and, global health experts thought, ambitious. Yet nine countries have already reached the more demanding 95-95-95 target—Botswana, Denmark, Eswatini, Kenya, Malawi, Rwanda, Saudi Arabia, Zambia, and Zimbabwe—and ten more are on track to meet next year’s deadline.

Tendayi Westerhof, a health activist in Zimbabwe, says good policy management put Zimbabwe ahead. “Everyone who is working on HIV/AIDS has to fit into the national strategy,” she says, “which is derived from the targets.”

But she warns there are many challenges to achieving the milestone—challenges that extend well beyond Zimbabwe. 

From the outset, global health architects were concerned about whether the health systems most impacted by HIV had the capacity to provide testing and treatment at the scale required. These worries became more acute as officials recognized that, due to stigma, they could not rely on people to just show up at health facilities for HIV testing and treatment.

The stigma is particularly detrimental for people in communities that are already marginalized—and sometimes criminalized. Those communities include sex workers, men who have sex with men (MSM), and people who inject drugs. These are often the same people most at risk for contracting HIV. Discrimination against these communities is sometimes buttressed by laws and policies, including some that criminalize homosexuality or sex work. Yet ensuring their access to services is crucial to reaching 95-95-95 in most countries, says Mary Mahy, who heads the collection and analysis of data at UNAIDS.

Around the world, officials have also learned to innovate and closely track the outcomes of the services they deliver—including testing and adherence, among the metrics—to ensure they are taking best advantage of finite funding.

Though each country’s path to 95-95-95 will be unique, the experiences of successful countries offer lessons for those that have fallen behind. Here are three solutions that have been particularly instrumental in getting and keeping people on treatment:

Community health workers

Botswana, which realized the 95-95-95 targets in 2022, began with an effort to combat the stigma around HIV, according to Peter Chibatamoto, the projects coordinator of Humana People to People Botswana, a grassroots program that aims to make HIV services more accessible.

Speaking on the sidelines of the 2024 International AIDS Conference in Munich, Germany, Chibatamoto says it became clear early in HPP’s efforts that fear and misunderstanding about the disease left people reluctant to use HIV services no matter how easy his organization made it. People did not trust health workers who tried to convince them they should know their status and, if they were infected, initiate treatment.

“There were so many people who would not want to go there,” he says—until the government enlisted local residents as community health workers (CHWs) who delivered basic services and connected people to the health system. Because CHWs know the local culture and have relationships with the people they serve, they are inherently trusted. This helps demystify the disease and encourages people to get tested and, if necessary, start treatment, Chibatamoto says.

In Cambodia, CHWs are called “lay counselors,” and they have been crucial to the country’s progress, says Vichea Ouk, the director of the National Center for HIV/AIDS, Dermatology and STDs in Phnom Penh. Cambodia has surpassed the targets for treatment and for viral suppression, and Ouk is hopeful the country will reach the testing target by the deadline. Teams that include people living with HIV work at health clinics, where they help dispel misconceptions about the virus and smooth people’s interactions with the health system.

In the past, a newly diagnosed patient might be overwhelmed by the glut of information, including details about when to pick up their medicines. The lay counselors follow up to make sure people show up for those appointments and absorb the importance of adhering to their daily treatment regimen.

Care outside of the clinic

Lloyd Mulenga is the head of infectious diseases at the national health ministry in Zambia, where officials struggled for years to reach the first 95. It was particularly hard to convince men to come to health clinics and get tested. After talking with community representatives, officials understood that the problem was not only about stigma but also a lack of time and prioritization, particularly for men with low incomes who worked long hours or held down multiple jobs.

Zambia is not alone. Across countries and continents, officials speak of the challenges people face paying for travel to far-flung health centers or securing childcare during their visits. Many see the same problem Zambia faced with getting men to clinics to test.

Starting in Lusaka, the Zambian capital, and the central Copperbelt region and working in collaboration with U.S. aid organizations, Zambian health officials launched a program to share information about HIV and facilitate testing at workplaces. Some versions of the initiative offered HIV self-test kits. Officials also arranged for clinics to stay open late and on the weekends so the men who used the kits had a place to drop them off and, if someone tested positive, to enroll in treatment.

Although the results of the initiative are still being evaluated, Mulenga credits the service with increasing testing among men and helping Zambia reach all three targets in 2023. Now, having spotted a gap in women over 50 getting tested, Zambian officials are considering borrowing from this model to set up discreet HIV testing services for women in markets and other places where they gather.

The overriding goal emerging globally, says Brian Chirombo, the World Health Organization representative in Rwanda, is to develop “client-centered approaches, which simplify and adapt HIV services to better meet the needs of people living with HIV.”

That includes members of marginalized communities who might be reluctant to visit a clinic. Cambodia has begun to offer HIV self-testing kits to MSM and sex workers, among others who worry about the stigma. People can even bring testing kits home for partners who might be too busy or nervous to go in person.

Decisions based on data

In Malawi, health ministry officials sit down quarterly to look at the performance of more than 850 healthfacilities. They review statistics such as how many new patients have enrolled, whether patients are adhering to treatment and maintaining viral suppression, and the stocks of antiretroviral drugs.

If they spot any problems, says Rose Nyirenda, the director of the National HIV, Viral Hepatitis and STI Program in Malawi’s Ministry of Health, they can rapidly respond. That might mean deploying officials to dispatch additional medicines or provide training to improve any performance issues that are preventing people from accessing or sustaining services.

Malawi has achieved this capability through more than 18 years of digitalizing HIV/AIDS data, which Nyirenda estimates has cost upwards of $180 million, mostly paid for by donors. But the expense has been worthwhile, she says, “because it has allowed the program to be able to look at the trends in many of the variables we collect” and act on them.

Now, the country is integrating artificial intelligence into some of its data collection services. The idea is that AI will help monitor data input for potential discrepancies and improve the quality of the information collected at the health clinics. It should also help reduce the time and money spent analyzing and summarizing the data, Nyirenda says.

More work ahead

Chirombo says reaching 95-95-95 is not necessarily about a single intervention but the willingness of a country to innovate based on data and international guidance. It’s an ongoing process.

Even as the officials and activists celebrate their success, they do not want this achievement to mask shortcomings that remain. In Rwanda and Zambia, for instance, children still lag behind the national percentages when it comes to receiving treatment.
Chirombo points to the ongoing need “to develop tailored approaches to address some of these groups that have been left behind.” It is another code he is convinced these countries can crack.

Top image: Obed Zilwa / AP Photo

The post What’s working in the 19 countries on track to help end AIDS appeared first on Harvard Public Health Magazine.

Tuesday’s vote will have an enormous effect on how—and whether—Nyambura and countless other health workers and reproductive rights activists around the world can do their jobs. Thanks to a longstanding rule about abortion that shifts each time the White House changes political parties, every U.S. presidential election pits the American mood against other countries’ sovereignty—and the health of their women and girls.

Nyambura has seen what happens when U.S. interests conflict with Kenya’s own laws and standards of care. She grew up in a low-income settlement, where girls’ lives were upended when they became teenage mothers. Four years ago, her cousin, then 20 and pregnant, couldn’t afford maternal health care. Already a mother, she died of a postpartum hemorrhage, orphaning her children.

Nyambura sees her cousin’s death as a symptom of the long reach of domestic U.S. politics—in particular through the Mexico City Policy, better known as the “global gag rule,” and the ways it shapes U.S. global health efforts. The policy was first instituted by Ronald Reagan, who restricted recipients of U.S. aid for family planning from using other donors’ money to provide abortion. Since it was introduced in 1984, the policy has been repealed by every Democratic president and restored by every Republican one.

Most Republican presidents followed Reagan’s lead, restricting several hundred million dollars of family planning funding. But President Donald Trump expanded the Mexico City Policy to restrict nearly all U.S. global health assistance—a far wider channel of funding, totaling $7.3 trillion by his last year in office. His administration, like those before it, meant to reduce abortions with the policy, but research shows abortions actually increase in years when the “gag rule” is in place. And some experts say Trump’s more restrictive reversion not only undermined women’s health care—it weakened other countries’ health systems more generally, including in Kenya.

“The organizations we work with were caught in the situation where they had to choose between accepting U.S. government funding or any other funding—for any other program. For example, if an organization had received funding from a European source to work on abortion care [along with] some elements of contraceptive care, they were ineligible for U.S. government funding,” says Angela Akol, until recently the regional director of Ipas, a global non-governmental organization that seeks to expand access to safe abortion care.

Akol saw the universe of partners who could work on reproductive rights in Kenya shrink. U.S. funding is simply too big to forego: The U.S. is the biggest external donor to Kenya’s health sector, and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) accounts for at least 60 percent of Kenya’s spending on HIV.

U.S. bureaucrats often insist abortion-related restrictions have the precision of a scalpel, but critics say that on the ground, they work like an axe, dismantling years of work, tearing through coalitions, and leaving millions of women and girls without the reproductive health care they need.

Nyambura knows it is impossible to attribute her cousin’s death directly to the rule. But she has also seen firsthand its profound ripple effects—even when the White House is controlled by Democrats and the policy isn’t in place.

Protecting the continuum of care

For this investigation, Harvard Public Health spoke with a dozen health workers, health sector leaders, and policy experts across the health sector in Kenya; most spoke anonymously to avoid potential professional or legal retaliation.

A U.S. State Department spokesperson, when asked for comment, underscored that President Joe Biden rescinded the Mexico City Policy upon taking office. The spokesperson told Harvard Public Health by email: “The United States has demonstrated committed leadership to global health while ensuring compliance with long-standing abortion-related restrictions on our foreign assistance.”

Nelly Munyasia, a trained nurse and midwife, is the head of Reproductive Health Network Kenya, a coalition of more than 600 health care professionals working in both private and public facilities. Her organization has created a network of referral facilities and support for women in need of comprehensive sexual and reproductive health care, including abortion care. In her view, the Mexico City Policy disrupts what she calls the “continuum of care” by wrongly assuming care providers like her can isolate abortion care from the rest of women’s health.

“No one opens a facility to just provide abortion care,” she says, “because no one comes in just for an abortion. They leave with a family planning method. You have to screen them for HIV if it’s a case of rape; [you] put them on pre-exposure prophylaxis. We are talking about access to contraceptives; we are talking about cancer screening and treatment.”

Saoyo Tabitha Griffith, deputy executive director of the health and human rights organization KELIN Kenya, says the U.S. anti-abortion regulations change the makeup of service delivery in Kenya—even long after the regulation changes. “Organizations known for offering holistic, 360-degree services stopped [doing so]. They started offering one-offs,” she says, describing care under Trump administration regulations.

Revoking the restrictions, as the Biden administration did, “doesn’t take away the loss of trust amongst your partners and peers.” Nor do patients automatically return, she adds. “The stroke of a pen . . . doesn’t erase the impact those four years have had.”

A dangerous legal gray area

In Kenya, the U.S. regulations stand in contradiction to the country’s own constitution, which allows for abortion when the procedure, in a health professional’s assessment, would safeguard the health or life of a pregnant woman. But there is no agreed-upon process for assessing when her health or life is at risk. Meanwhile, the country’s penal code—written by the British during the colonial period and adopted as national law at independence, in 1963—criminalizes both seeking and providing an abortion. Women could receive sentences of up to seven years in jail for seeking an abortion, and their health care providers could face up to 14 years in jail for providing one.

The contradiction between the penal code and Kenya’s more recent constitution, adopted in 2010, was supposed to be resolved by Parliament. It never has been. In recent years, anti-abortion groups have actively exploited this legal and policy stalemate by further blocking any attempts to pass progressive legislation. Health workers and researchers alike say that the resulting confusion undermines health care outcomes and service delivery.

Dorcus Muchiri, a doctor and OB-GYN, has experienced the impact of the policy lacuna. In 2008, a 16-year-old girl came to the clinic where she worked seeking an abortion. Staff there told her it was illegal and sent her away. Three days later, she returned, saying she was feeling unwell. In surgery, doctors discovered she had a perforated uterus, the result of an unsafe abortion attempt. “She died on our operating table,” she says.

At least 2,600 other women in Kenya also died from complications after seeking unsafe abortions that year. This case happened before the Kenyan constitution that permits abortion in some cases became law, but it still haunts Muchiri. Even now, she and other health workers say, the lack of clear guidelines means they err on the side of the Penal Code regulations that deem procuring or aiding in an abortion a crime. In the vast majority of cases, doctors only provide post-abortion care, Muchiri says, because that care is unambiguously legal: Medical regulations say that doctors are mandated to save a life by providing emergency services to patients facing imminent death.

“These are not medical lines that we are drawing,” she adds. “Even the supplies that are needed to save the life of a woman who has shown up bleeding from a self-procured [abortion] are the same ones [as] if she was seeking a safe termination. It’s the exact same kits, commodities, and equipment.”

U.S. domestic politics vs. Kenyan health sovereignty

U.S. policy has exacerbated Kenya’s challenges in reconciling its abortion laws. In 2012, the Ministry of Health launched guidelines for safe abortion, intended to bring clarity on the gray areas of Kenya’s laws and regulations and to guide clinicians and patients in making decisions about appropriate abortion care. But in 2013, the Ministry of Health’s director of medical services withdrew these guidelines—just one day after the senior health manager for the U.S. Agency for International Development (USAID) in Kenya sent an email to more than 50 USAID grantees, barring them from attending a ministry meeting where those guidelines would be discussed. In February 2014, the ministry further prohibited health care providers from receiving training on safe abortion procedures.

USAID did not respond to a request for comment. The U.S. State Department did not respond to questions about the impact of the Mexico City Policy on USAID policy or practice.

The stalemate on safe abortion guidelines sparked a protracted court case, which culminated in a landmark verdict, in 2019, that affirmed a constitutional right to abortion in certain circumstances. The ruling also restored the standards and guidelines for reducing morbidity and mortality from unsafe abortion. At least in theory, the ruling put to rest the contradiction between the Penal Code and the constitution.

But in practice, health workers told Harvard Public Health, confusion and fear still affect medical workers’ decisions, and many continue to follow the more restrictive Penal Code.

In these circumstances, clarity on clinical standards and guidelines around abortion became even more important; still, the bureaucratic process remained protracted. Last year, the ministry finalized guidelines around unsafe abortion as one among the five top causes of maternal mortality—but according to documents obtained by Harvard Public Health, resistance from anti-abortion groups pushed the ministry to cancel its public launch. “So officially, the people have copies of the guidelines, but they’ve not been launched,” says Kenneth Juma, a researcher at the African Population and Health Research Centre (APHRC) whose work focuses on maternal and reproductive health.

Kenya’s Ministry of Health did not respond to requests for comment.

Canceling the launch was not a minor bureaucratic detail; it was a missed opportunity to give official direction clarifying the issue, which is what all the stakeholders—especially medical providers—had been asking for over the years. “Guidelines are supposed to streamline and offer guidance . . . to actors within the health system space,” Juma explains. “So that is health care providers, but . . . patients benefit when there are clear guidelines. So anytime we do not have guidelines . . . there is confusion, [and] knowing abortion, people then self-censor, maybe over-restrict, or sometimes under-restrict whatever they are supposed to provide.”

Meanwhile, doctors say, the legal process has sidestepped an equally important issue: the wider context in which women and their providers face choices around their pregnancy.

“I’ve never been trained on termination of pregnancy for viable pregnancies, where the patient has a nonmedical reason to want one. It’s not a topic we discuss in medical school,” says Muchiri. “But to be frank, abortion is not just a medical question. It’s a social question—there are all kinds of social reasons why a pregnancy might be medically viable but not socially viable for the woman in question. We have to think of this as a bigger question that not only doctors can answer.”

Data show that U.S. anti-abortion regulations undermine sexual and reproductive health outcomes generally—even in countries where abortion is legal. In Kenya, some organizations that refused to be bound by the U.S. policy saw other funding dry up, amplifying the services shortage. Individual organizations, says Akol of Ipas, might try to comply with U.S. rules in the short-term and focus on staying open in the long term—but the patients they serve don’t have the same luxury.

“Women’s lives are not synced to the U.S. election cycle,” she says.

Juma, the APHRC researcher, says sexual and reproductive health nonprofits work in close collaboration, thanks both to tight budgets and to the vast terrain they must cover. “So when the U.S. comes and says, ‘You’re not allowed to partner; you’re not allowed to collaborate; you’re not allowed to share resources’ . . . you’ve fractured that collaboration,” he says. 

One HIV/AIDS organization in Nairobi was warned by USAID not to share space in its vehicle with groups that might transport “abortion-related commodities in their car since the car was procured with USAID funding,” he says. “You don’t even want to be seen in any meeting because even being seen in a meeting can have detrimental effects.”

This level of attention to partner activities has a chilling effect across the health sector, multiple providers told Harvard Public Health. “I never saw any USAID official on the ground,” says Griffith, of KELIN. “But what we saw was just overzealousness of our own partners. They wouldn’t even come to our meetings. . . . even when the meeting was on HIV and TB. They just don’t want to be associated with us.”

Whatever the outcome of the U.S. poll, Griffith worries about what could happen in just a few short months in Kenya. After four years of Biden, she says, if a Democrat loses, “all the efforts made to restore confidence, refund organizations that lost funding, and inform local communities about the availability of safe abortion services might be undone.”

Image: In a file photo from 2009, Dr. Aron Sikuku, right, explains family planning pills to Beatrice Ravonga, in a clinic in a Nairobi neighborhood. Family planning and reproductive health funding are often subject to the restrictive Mexico City Policy. (Khalil Senosi / AP Photo, File)

The post How the U.S. election has an outsized effect on global reproductive health appeared first on Harvard Public Health Magazine.

On Aug. 14, the World Health Organization named mpox a global public health emergency—for the second time in two years. When the first declaration was issued in 2022, preexisting smallpox vaccines offered hope that the mpox virus could be controlled more quickly than SARS-CoV-2, the virus that causes Covid-19. However, similar inequities in vaccine access and scant international cooperation marred sustained containment efforts.

For years, mpox has been spreading in Central and West Africa, where two lineages of the virus have become endemic. Spanning from Sierra Leone to Nigeria and parts of Cameroon, clade II typically causes less severe disease with lower mortality than its counterpart clade I, which is found in the Congo River Basin and bears fatality rates of up to 10 percent. A new variant from clade I is currently responsible for the high disease burden in the Democratic Republic of Congo—and, for the first time, cases in nearby Burundi, Rwanda, Kenya, and Uganda—and has stoked the international emergency. Sweden and Thailand have also recently identified the variant in travelers arriving from the region. Nevertheless, the continent facing the brunt of mpox still sorely lacks vaccines, with 10 million doses needed but only 200,000 becoming available as of mid-August, according to Jean Kaseya, director-general of the Africa Centers for Disease Control and Prevention. This injustice has a long arc.

From yellow fever to Ebola, Africa has been consistently shortchanged on essential supplies to tackle infectious diseases. During the Covid-19 pandemic, African countries experienced delays in receiving their fair share of personal protective equipment, antivirals, and other resources, despite being expected to participate equally in disease control. For mpox, none of us are surprised about the recurrence of uneven vaccine access; this has been a persistent motif in global health.

We are sympathetic to the reasons why Western countries, faced with the possibility of mpox, would prioritize their own vaccine needs. But this speaks to the predicament of balancing self-interest and equity.

One proposal to expand vaccine access is through donation-based schemes, which don’t always work. Take for example the Covid-19 Vaccines Global Access Facility, or COVAX—a large-scale, public-private partnership designed to enhance equitable distribution of Covid-19 vaccines. At the end of 2021, the G7 and European Union had a collective surplus of nearly 770 million Covid-19 vaccines while COVAX simultaneously fell 1.5 billion doses short. Africa specifically saw a deficit of just under half a billion Covid-19 vaccines that would have been critical for meeting its annual vaccination objectives. In a familiar retelling of this story, just before the WHO first labeled mpox an emergency, North American and European countries bought up and stockpiled millions of doses of an mpox vaccine produced by Bavarian Nordic.

As such, moving towards equity means first shifting away from a consumer to a producer model. Some pharmaceutical companies currently have end-stage fill and finish manufacturing in Africa for drugs and vaccines, which entails loading bottles with pills and preparing syringes for distribution. However, sustainably addressing vaccine inequity will require a homegrown effort to build the whole pandemic value chain—the end-to-end process of vaccine manufacturing—on the continent.

There are some promising signs ahead. When the 2022 mpox outbreak was ramping up, the Partnerships for African Vaccine Manufacturing, or PAVM, unveiled a Framework for Action to expand the continent’s vaccine manufacturing capacity to satisfy 60 percent of its own supply in the next two decades. Importantly, the framework places Africa in the driver’s seat, establishing pooled procurement mechanisms, a formalized process for preparing and financing manufacturing deals, and a unit that can promote enough technology transfers to generate at least 1.5 billion vaccine doses annually within this timescale.

While Africa will steer this effort, it need not do all the work alone. In fact, PAVM’s framework explicitly summons all parties “to play their part in bringing us to ‘the Africa we wish to see.’”

These contributions must be multifaceted. First, the WHO should encourage pharmaceutical companies to participate in technology transfer so that Africa can meet its vaccine manufacturing goals. Though potentially challenging due to intellectual property law, there is precedent: In 2022, Bavarian Nordic announced a technology transfer agreement with Michigan-based Grand River Aseptic Manufacturing. At the time, the company’s chief financial officer, Henrik Juuel, told Reuters that interest in their mpox vaccine was “overwhelming.” A similar pivot towards Africa is long overdue and attainable with robust international pressure. The initial success of South Africa’s WHO-sponsored hub for mRNA vaccine technology underscores Africa’s readiness to meet the pharmaceutical industry and other global stakeholders halfway.

Second, international partners can support the homegrown expansion of research and development capacity within Africa, ensuring that countries have the tools to proactively address their own health needs. For example, PAVM’s framework emphasizes opportunities to bolster the continent’s pharmaceutical value chain, such as increasing the number of animal research facilities and creating a coordinating platform for large-scale R&D activities. Industry and academic affiliates can further encourage these ongoing efforts by plugging African scientists into their knowledge networks and research collaborations.

Third, alongside expanding vaccine manufacturing, Africa should lean into its time-tested strengths for infectious disease control. For example, community networks on the continent have historically facilitated robust contact tracing, public messaging, and isolation of cases during outbreaks. Such community-based practices have also established a tradition of prioritizing the vaccine needs of high-risk groups like health care workers, a pragmatic strategy that should be used to manage mpox until more doses are available.

More broadly, we should revisit how Africa is treated in future global health affairs. For starters, the WHO can rally development institutions and nongovernmental organizations to serve as a countervailing force to vaccine nationalism and myopic private interests. This may entail the WHO redefining its scope of authority and reforming the levers it can employ when member states inappropriately engage in rampant vaccine hoarding. To this end, some legal scholars have advocated for the organization to eschew wide-reaching global health governance in favor of a sharper focus on infectious diseases, a concentrated approach that could enable greater consensus-building among parties.

It is also high time for countries to come back to the negotiating table and ratify a Pandemic Preparedness Treaty—one that reevaluates vaccine-sharing mechanisms to prioritize high-risk regions. For instance, during the first global outbreak of mpox, the WHO announced plans to supply doses to 30 countries outside Africa, despite these countries having lower disease burdens than African countries. Ahmed Ogwell, then-acting director of Africa CDC, in turn, said that “the place to start any vaccination should be Africa and not elsewhere.”

Covid-19 spotlighted how vaccine inequity is persistent, pervasive, and almost inevitable, especially as climate change, population growth, and more frequent human-wildlife contact incite more pandemics. Mpox could be an opportunity to turn the page and rebalance global health priorities.

Image: Colorized transmission electron microscope image of a mpox virus particle (yellow) found in an lab-cultured infected cell (blue). (NIAID / NIH)

The post Mpox offers another chance to confront vaccine inequity appeared first on Harvard Public Health Magazine.

“Far from elimination, the entire program is floundering, and we do not have even a modicum of control [of tuberculosis] at the community level,” says Yogesh Jain, a physician who runs Jan Swasthya Sahyog, a community health program in rural Bilaspur, Chhattisgarh. Jain says the fight against TB was “upended by COVID-19.” Plagues shape other plagues, and the pandemic meant shifting resources away from TB and other diseases, a change that also weakened the health system. “We cannot even do the basic task of getting medicines to patients; forget active surveillance or treating latent TB,” Jain says. “The poorest people are the most miserable,” he adds. Some 80 percent of the country’s TB cases involve people in the lowest income quintile.

Tuberculosis kills more people in India than any other infectious disease. India also has the highest burden of people with drug-resistant TB, with 119,000 cases reported in 2021, out of 2.8 million total. TB is not the only infectious disease that India is struggling to contain. It may have the largest number of people with HIV, which is also on the rise; the country reported 60,000 new cases in 2021. The prevalence of both diseases has likely increased because of frequent drug shortages.

The reversal is astonishing, says Ganesh Acharya, a TB activist. “We are forgetting the meaning of airborne pandemics right after getting out of one,” he says. “It is like we have learnt nothing.” He calls it “a situation of complete apathy” on the part of the government. Government officials did not respond to requests for comment.

India’s TB response went into a tailspin because of three main factors: widespread shortages of drugs, failure to implement the latest WHO-recommended approaches, and the seeming inability of the government to respond to the worsening situation. Observers say shortages of drugs are especially frustrating in a country that is the world’s leading producer of medicines. India makes drugs used to treat the disease variants that respond to antibiotics, known as drug-sensitive TB, and the ones that must be treated with stronger drugs, known as drug-resistant TB. But the country’s drugmakers also supply international groups and foreign countries, and they cannot necessarily respond quickly to changes in need within India. In a cruel irony, Indian patients faced shortages while Indian-made medicines were being shipped abroad to organizations like the Global Drug Facility.

Between 2019 and 2024, the country saw three nationwide shortages of treatments for drug-sensitive TB, which patients must take over a six-month period. Last year, shortages spread to the drug cocktails used to treat drug-resistant TB variants. These courses of treatment can run for two years, and they often have serious side effects.

The shortages were acute in September 2023, when global health leaders attending the United Nations General Assembly gathered for a high-level meeting on TB. That session ended with a renewed commitment to eliminate the disease globally by 2030. Meanwhile, Indian TB patients were on social media decrying their inability to get drugs. Indian government officials, speaking on condition of anonymity, expressed an uneasy sense of déjà vu. A similar problem had unfolded during the pandemic. Through April 2021, India delivered more than 66 million doses of vaccines to 95 countries, more than it used domestically in vaccinating only four percent of its own population. When the Delta variant emerged that fall, killing 2.7 million Indians in four months, India’s government curtailed exports for several months, one of multiple developments hampering pandemic response around the world that fall.

Production challenges are not the only issue. At least one promising new TB treatment was until recently stuck in bureaucratic red tape. A revolutionary treatment for drug-resistant TB called BPaL had a 90 percent cure rate in a clinical trial and did not cause deafness, a side effect of existing treatments. The Central Drugs Standard Control Organisation, India’s drug regulator, approved BPaL in 2020. But the Indian health ministry was slow to publish national guidelines for the treatment, even after the WHO urged countries to transition to BPaL in 2023. That same year, India’s health ministry ran a successful pilot involving 400 patients at 13 hospitals. But while 75 other countries were introducing the new drug, India did not move forward until its National TB Elimination Programme (NTEP) finally announced on August 10 that it would begin rolling out the drug. Officials did not respond to questions about the delay. But it came about a month after the appointment of Soumya Swaminathan, the WHO’s chief scientific officer during the pandemic, as an advisor to the NTEP, a move that some in India see as a sign that the country is working to improve its response to the disease.

The Indian government has the power to take other actions, notably to address undernutrition. Being undernourished is one of the biggest underlying risk factors for TB infections, because it both weakens the immune system and makes it difficult for people not to throw up their TB medications. RATIONS, a landmark study published in 2021 with follow-ups in 2023, found that TB incidence could be cut by nearly half simply by providing food baskets along with TB medicines. “Undernutrition is not a phenomenon that will go away,” says Anurag Bhargava, a professor at Yenepoya Medical College in Mangalore and the principal investigator of the RATIONS trial. He adds that the United States Agency for International Development implemented pilots in two districts of Madhya Pradesh, which were also seeing favorable results. India’s government in 2018 began providing TB patients with some food support but has so far not expanded that initiative, despite the trial results.

India is also at odds with the WHO, and the dispute is damaging the global fight against TB. Relations chilled in 2022, when the WHO released country-by-country data on excess mortality from COVID-19 and placed deaths in India at 4.7 million, nearly 10 times the country’s officially reported figure of 480,000. India was the only nation of the 194 in the WHO report to contest the mathematical models used to arrive at these figures.

Indian leaders were conspicuously absent from last fall’s multilateral TB gathering at the UNGA in New York. The global leaders—the WHO’s STOP TB Partnership as well as organizations like the Bill & Melinda Gates Foundation—have praised the Modi government for sticking to its 2025 commitment. But Chapal Mehra, the convenor of Survivors against TB, says, “[I]f we have no drugs, no budgets for expansion, and there is no justice … will that commitment translate to anything?” Experience suggests it will not—global TB targets have been set (1991), reset (2000), revised (2011–15), and woven into Millennium Development Goals (2015).

Right now, every U.N. global milestone for TB is lagging behind expectations. Reducing deaths is short by 56 percent, reducing cases by 41 percent, and making treatment affordable by 49 percent. India’s lapses are part of the reason for these shortfalls. Tuberculosis has always been an important litmus test for global health, revealing failures of policymakers decade after decade as perhaps no other plague does. India is not alone in seeing increases in TB; the disease is on the rise in Europe, in part because of the war in Ukraine, and in the United States, where California and New York have seen hot spots fuelled in part by budget cuts affecting efforts to fight infectious-disease outbreaks. India’s failures are not to blame for these occurrences, but raise concerns about health systems left understaffed and overwhelmed by the pandemic.

It would help if the international community could rally around TB the way it did around HIV/AIDS in the 1990s, says Robyn Waite, an independent researcher and TB advocate. She says India today resembles the situation in South Africa during the height of the AIDS crisis—patients left without medicines, families ruined, communities compromised, while the government insists that things are under control. In that time of crisis, HIV also affected people in high-income countries, making it easier to marshal resources, she says. TB has some global allies, but, Waite says, “there aren’t many people in high-income countries with recent experiences of TB to support the cause in the same way.”

The situation is especially frustrating because “India can be a model for the world, a country with enormous—though maldistributed—resources and incredible ingenuity,” says Carole Mitnick, a TB researcher and professor of global health and social medicine at Harvard Medical School. Indian activists agree that the country has the tools needed to drastically reduce infections and the logistical know-how to organize mass elimination campaigns. Instead, Indian patients can find themselves stuck in a drug desert.

Physicians like Jain say they too often face impossible choices in deciding which patients should get scarce doses of medication. “When we cannot even guarantee the reliable supply of medicines, we play havoc with the lives of patients,” he says.

Global TB intervention cannot succeed without the world’s most populous country taking the lead in combating the illness. Until India again is making substantial progress against the disease, prospects for a world without TB look bleak.

Image: Tuberculosis medications at a clinic in Delhi, India. Supply shortages have been an ongoing problem in the country. (Andrew Aitchison / Alamy)

The post The battle against tuberculosis will be won or lost in India appeared first on Harvard Public Health Magazine.

—Paul Adepoju

(Study in The Lancet Infectious Diseases, May 2024)

The post We need better rapid tests for Lassa fever appeared first on Harvard Public Health Magazine.

But today Onyango, the school’s principal, is bragging about something much more basic: Thanks to an innovative community program, his students and teachers are no longer getting sick from dirty water.

Onyango’s school, with a staff of 30 and a student body of about 1,700, is in Kibera, a neighborhood in the Kenyan capital of Nairobi that is widely known as Africa’s largest informal settlement. It is a community of houses made from mud or tin sheeting where residents have to hustle to meet even their most basic needs, like electricity or clean water.

It is also a community where creativity and innovation, at the heart of any hustle, are changing how some people can access clean water—and making major ripples in public health.

Onyango’s school has long gotten its water the same way many people in Kibera do: by buying it from independent suppliers, who truck water in and sell it for around $30 per ten thousand liters. But trucked water can be contaminated, despite suppliers’ promises, and Onyango’s students and staff were often using unclean water at home, too. It was common, he says, for both teachers and students to get sick and miss school because of water-borne illnesses.

Last November, Onyango’s school got connected to an aerial clean water system built by a local grassroots organization called SHOFCO, which stands for Shining Hope for Communities. “Once we got connected to SHOFCO’s water,” Onyango says, “cases of these ailments reduced to nil.”

Access to safe drinking water—and its equitable distribution—underpins public health. But for the estimated 250,000 people in Kibera, who live without any government infrastructure, clean water is often a luxury. Many people are using illegal water connections, which proliferate among the poor—there are nearly 130 in just three lesser-resourced Nairobi neighborhoods. But those DIY hookups can mix clean water with raw sewage, and Kenyan officials have recently warned of a looming public health crisis if water access is not prioritized.

Shifting weather patterns also increase the risk of waterborne illness, government officials say. The Ministry of Health and the Kenya Red Cross Society have called out severe flooding during the El Niño weather pattern as a source of a recent major cholera outbreak in parts of the country. Kibera was not spared this risk: The floods led to the contamination of various sources of water in the sprawling neighborhood.

But the aerial piping system SHOFCO built in 2012—the one that brings water to Onyango’s school—saved some Kibera residents, quite literally. With collaboration from health and county authorities, SHOFCO has all but eliminated diarrheal disease in the communities that use its aerial piping system, according to Gladys Mwende, a program officer at SHOFCO. In the health facilities SHOFCO runs, the incidences of diarrheal infections have also gone down, she adds.

“[Poor sanitation is the reason] that our water is aerial piped,” says Kennedy Odede, the founder and CEO of SHOFCO. Piping water in helps clean water maintain its integrity without interference from elements including tampering. In a huge community with no major infrastructure, piping seemed impossible—there was no money and no will to build a disruptive underground system connected to the city’s main water supply. Instead, Odede and his team put the pipes up in the air. “As somebody who grew up in Kibera, to see this clean water—which I have also drank—is powerful.”

SHOFCO’s water distribution system currently reaches about 40,000 people and distributes more than 14 million liters of clean water per month—nearly 173 million liters per year—at community water kiosks, which residents access with tokens linked to the mobile money platform M-Pesa. The water kiosks are pre-programmed to fill jerry cans that hold 20 liters, or about five gallons, at a cost of 3 Kenyan shillings, or about 23 U.S. cents.

A recent evaluation of SHOFCO’s clean water efforts, undertaken by the African Population and Health Research Center, shows diarrheal disease among children under age five have decreased by 31 percent where community members used SHOFCO water kiosks and received SHOFCO’s sanitation messaging.

“We don’t get as many cases of diarrhea even though now we are in the middle of the floods,” Mwende says. “Communities have not reported any outbreaks within the areas where we are working.”

Mohammed Suleiman is grateful for the change. Suleiman, 25, was born here, and it’s been his job for the last 18 years to fetch 500 liters (135 gallons) daily for his family’s personal needs and for their samosa business.

Two months ago, Sulieman contracted typhoid from the unsanitary water he was consuming. Once he recovered, he says, switching to SHOFCO water kiosks was a no-brainer.

“I don’t know where the other independent vendors get it from,” he says. But he trusts SHOFCO water. “Water sourced from SHOFCO is cleaner than that of other vendors,” he said. “I don’t have to treat water from [SHOFCO] kiosks before consuming it.”

And he’s the living proof: Since switching to SHOFCO water, Suleiman hasn’t been sick even once.

Top image: People in Kibera’s Makina section pass by the signature blue pillars that hold up SHOFCO’s aerial water piping system.

The post How Kibera’s water woes vanished into thin air appeared first on Harvard Public Health Magazine.