By  Dr. Daniel Feiken

“My lovely girl is gone.  My lovely girl is gone.  My lovely girl is gone,” the young woman wailed.  A clutch of family members supported her limp body, her immobile feet dragging across the floor as if she were levitating.  A crowd behind the waiting area barrier watched the spectacle with stony faces.  People in the crowd held up signs – “Karibu Kenya – Micato Safaris,” “Mt. Holden Ministries – Kenya Summer Tour, July 2011,” “Mr. V. Patel” – momentarily lapsing in their scanning of the faces of the arrivals for a smile of acknowledgment. The woman, still chanting her lugubrious refrain, was ushered out of the Arrivals Hall at the Kenyatta International Airport into the cool darkness of the Nairobi night.

It was a fitting welcome mat for my return to Kenya. I left a year ago after having lived here for six years.  Although I never got rid of the deep gnaw inside that scenes like this evoked, I came to expect their regular interruptions in my daily life. The outer layers of life are peeled away here, exposing a raw core of existence that is mostly swaddled in America.  Violence, poverty, illness and especially death, lurk everywhere. In the villages, in the urban slums, on the roads, in the wild bush. Death is not an abstract notion here. Nobody writes books about it. During my time here, I knew few Kenyans who did not suffer an unexpected or premature death in their families. Children bore a disproportionate burden of these deaths. Still in Kenya, one in ten children die before their 5th birthday; in some areas, it’s two in ten. So the story that quickly dovetailed in my mind when I saw the distraught young woman in the airport was that she had been working abroad, sending money back for her family, including her baby daughter, who she had just been informed had died from a sudden illness. In my mind, that illness was pneumonia, because pneumonia is one of the leading causes of child death in Kenya and because pneumonia is the disease that I work on. The most likely culprit in my story was pneumococcus, the bacteria that causes the most pneumonia deaths in the world.


I recently watched the spiffy graphical display put together by Hans Rosling, demography’s Swedish conjurer, of the progress that has been made in global child mortality over the last century. On an animated graph, multi-colored and multi-sized spheres, depicting countries by continent and size, slide their way from the lower left quadrant (representing high child mortality) to the upper right quadrant (representing low child mortality) over the last century as their child mortality rates drop. Rosling relishes pointing out how the cluster of Asian spheres, mired in the lower left for the first few decades of the 20th century, have in the past half century sprinted towards the upper right, now nipping at the heels of North America and Europe.  Improvements in health, he points out, generally precede improvements in economies. The flight of the Asian tigers has left a lonely club of mostly African countries at the bottom. Watching the graphical display in motion several times, another feature of the display’s kinetics strikes me – individual countries don’t just move gradually in one direction, but rather bounce up and down in spikes, their trajectory looking more like a seismic reading than a smooth vector. Some of these annual spikes have obvious explanations – most countries plummet precipitously with the 1918 influenza epidemic and during World War II. What is less clear is why some countries seem to leap up when they do. I suspect that these are more idiosyncratic, likely related to individual government policies, or perhaps to the advent of public health interventions. If it is the latter, then 2011 could likely be one of those upward blips for Kenya.  


On February 14th of this year, the Ministry of Health of Kenya officially introduced the pneumococcal conjugate vaccine (PCV) – designed to protect young children from the most common cause of vaccine-preventable death - with support from GAVI and the Advanced Market Commitment (AMC), an innovative international financing mechanism making it possible for the world’s poorest countries to sustainably introduce the latest, most sophisticated pneumococcal vaccines. Kenya joined only a handful of other sub-Saharan African nations who have introduced PCV including South Africa, the Gambia and Rwanda.  The Kenyan Division of Immunization Services had been waiting for several years for this day – securing nods of approval from the Ministers of Health and Finance, expanding cold chain capacity and training immunization staff on the intricacies of administration of this new vaccine. At the official launch of PCV in Kenya, there was a well-deserved, shiny moment of pomp, congratulatory handshakes and high-minded speeches. But beyond that, the introduction happened smoothly and efficiently, without fanfare, in the hundreds of immunization clinics scattered across this vast country.

The other day I went to one of those clinics at Lwak Mission Hospital, where I used to work in rural western Kenya. I like to go back to the field when I return to Kenya. The sights, sounds and smells of rural Africa reconnect me to the reasons I got into global public health in the first place. At Lwak Hospital, the benches were full of mothers waiting with their babies for their immunizations. I spoke to the male nurse who operated the clinic. He excitedly explained how the demand has been fantastic, with mothers bringing in babies even beyond the indicated age for vaccination (i.e. 6 weeks - 11 months) to inquire if they could get the “pneumonia” vaccine for their babies. He showed me the supplemental sticker that had been designed to put on the immunization card to indicate the date and dose of PCV administered. Then he reached into the cool box and brought out the two-dose vial of PCV.   Knowing something about the vaccine’s complicated history – the technological sophistication of its design, the intricacies of its financing hashed out among high-level officials in meeting rooms in Geneva, London and Rome and the politics of its licensing – the tangibility of that diminutive vial in a cheap plastic cooler in a remote African village startled me somewhat. Yet, there it was, about to be injected into the chubby thighs of the babies waiting in the queue. 

 
This unassuming scene, it dawned on me, held the story and the promise of a sudden upward tick for the Kenyan orb on Hans Rosling’s graphic. That rise, if the epidemiology of pneumococcal disease in Kenya goes as expected from previous experience with PCV, will be what the world will see and remember about the vaccine’s introduction in Kenya. But the unseen story, perhaps, will be a quieter one. It will hopefully be the quiet of future arrivals at the airport in Nairobi.

Dr. Daniel Feiken is the Director of Epidemiology at IVAC.