Kenya: The cholera test and why the Kenyan health system has failed

By: Dr Stephen Wanjala, Deputy Medical Coordinator for Médecins Sans Frontières in Kenya

Over 128 and 30 suspected new cases of cholera have been reported in Migori and Kisumu counties respectively in the past one week. This is amidst a number of political declarations across many counties that the cholera outbreak is over. To me this is one of the strongest attestations to the lack of clear coordination in outbreak response within the devolved framework. If such an approach is aimed at downplaying the outbreak in order to save face then it is a recipe for disaster and the short rains expected in September are only likely to make things worse.

The first cases of cholera can be traced to December 2014, yet several counties delayed in declaring the outbreak and responding appropriately because they were concerned it would cause shame and anxiety among the population.

It got me wondering; what would President Obama do if the US Centre for Disease Control (CDC) was unable to contain a relatively small outbreak of cholera in one of the states for a period of 8 months and running? When the two leaders meet on Saturday at statehouse, President Uhuru is likely to include in his brag sheet the strides being made in maternal and new-born health largely due to the beyond zero campaign. What he is not likely to mention is that the Ministry of Health and the county departments of health have been unable to effectively control the ongoing cholera outbreak in reasonable time to a large part due to slow responses in many counties, as well as the lack of clear harmonisation between national and county governments. The Government declared it was allocating KES 500 million for this outbreak.  Without proper coordination between the national and county governments, resources such as these will result in inadequate impact.

As a nation, we must answer key questions concerning the mandate and jurisdiction of the national and devolved governments when it comes to controlling infectious disease outbreaks or other national disasters. Who is in charge of detecting and controlling the outbreaks? Who should be held accountable for a poorly managed outbreak? How do we avoid turf wars between national and county governments when it comes to outbreak response?

In the US, the CDC has its mandate clearly defined as the health protection agency. Its jurisdiction is not limited by internal geographical boundaries and even extends beyond its borders.

With a clear mandate, jurisdiction and pre-positioned resources, the health protection agency of a country should be able to swiftly respond to outbreaks within its borders without having to face the obstacles of bureaucracy.

In the current legislative and operational framework county governments have made formal requests to the national government for support. Other Counties tended to deny the outbreak. In most cases, the request was delayed mainly to avert ‘the shame’ that comes with cholera.  A more progressive arrangement would see officers from the national government swiftly spring into action based on the notification of one case on the basis of clearly defined mandate and jurisdiction.

The ongoing cholera outbreak does not make a case for or against devolution of health; but is surely makes a case for the need to clearly define the mandate and jurisdiction of national and county governments when it comes to cross county outbreak response. This clarity will be lifesaving in situations of time sensitive ravaging outbreaks such as Ebola where inefficiencies due to inter-governmental turf wars did certainly fuel the outbreak out of control.

I have to hail Cecila Mwangi, Miss World Kenya 2005, who has taken up the cause of jigger infestation that was wrecking poor communities in central Kenya. Cholera shares this predilection for the poor with jiggers. Maybe it is for this reason that various departments of health are rushing to declare the cholera outbreak over in order to avoid the ‘shameful’ spotlight it shines on our health and social systems. Perhaps more appropriate response would be to address the system inefficiencies that have led to a prolonged and resurgent outbreak, while at the same time preparing for the upcoming short rains in September that may fuel the outbreak further.  

Dr Stephen Wanjala, Deputy Medical Coordinator for Médecins Sans Frontières in Kenya

Since the beginning of the current outbreak in December 2014, Médecins Sans Frontières (MSF) has been involved with county governments in dealing with the recent cholera epidemic. MSF has supporting 56 facilities in 11 counties (Migori, Homa Bay, Bomet, Nakuru, Nairobi, Muranga, Kiambu, Embu, Machakos, Narok, Kisumu), that have provided care and treatment to 5734 patients. This through supporting case management with additional 473 national HR (cumulative), training, epidemiological follow up and supplies.

Nairobi County has been particularly affected as MSF teams recorded 2644 admissions by week 28 including locations such as Mathare, Mukurus or Kibera.

MSF is particularly concerned that this epidemic may follow the pattern of past cholera epidemics that peaked months after they started. MSF is calling for the national government to not declare the outbreak over and for counties and for all actors to remain vigilant in the coming weeks or months in order to be able to swiftly respond to any further upsurge and avoid unnecessary death.