By Eric Goldscheider
Photos by: Betsy Charron*
The news from the front lines of the global fight against tuberculosis is not good, according to Kate Macintyre, a professor of international health and development who has been at Tulane since 1997. Four years ago, Macintyre moved her base of operations to Kenya. The East African country ranks number 13 on the World Health Organization’s (WHO) list of 22 high burden tuberculosis countries. But the relative scale of the problem is only part of the story Macintyre told during an interview in the office she rents from a safari company in Karen, a Nairobi suburb. The real tragedy is that Kenya has met or exceeded all the recommended steps for fighting the disease over the last decade. “In other words, the targets aren’t enough,” says Macintyre, “and that’s pretty depressing.”
The rates of tuberculosis infection are “worse than anything that was seen in Europe and America in the 19th century, to put it in context,” says Macintyre. Kenya has about 110,000 cases annually, which translates into more than 350 cases per 100,000 people. The AIDS epidemic is widely regarded as “fueling” a growing tuberculosis crisis, according to Macintyre, because people with compromised immune systems are more susceptible to tuberculosis. “They call it the twin epidemics now,” she says. “Most people with AIDS die of tuberculosis.”
Macintyre’s training and proclivities as an academic are grounded in the social sciences. She is interested in human behavior as it relates to infectious diseases. She also has a strong grounding in policy, coming out of her training as a demographer that included a great deal of work in history, political science, and sociology. In addition to tuberculosis most of her work has been on malaria and the human immunodeficiency virus (HIV), which leads to AIDS. She is working on projects in Zambia, Swaziland, South Africa, Ethiopia and Eritrea. Earlier in her career she also worked in Latin America.
Before transplanting herself to Kenya from New Orleans, Macintyre says she was spending much too much time in airports. “I find it very very important to be close to the three epidemics so I did a lot of travel and I was exhausted,” she says, “I really wanted to come witness – that’s really what it is – witness the situation and get close to it.” Now she comes back to New Orleans in May to teach a course on health policy in which she draws on her real-world knowledge of how the battles against these diseases are being waged. “I can say, ‘right, this is what I’ve been doing and let me tell you what I’m seeing happening’… [we] look at the way policy makers maneuver, who the stakeholders are, and how they make decisions.”
Macintyre is currently working on the national tuberculosis strategy for Kenya under the auspices of the Ministry of Public Health and Sanitation. This involves pulling together data and information from a group of about 60 stakeholders who include senior policy makers, the heads of nine regional offices and members of the donor and advisor communities. She describes it as “a plan of what to do in the next five years and how we can contain the disease.”
While she didn’t generate the data showing that Kenya’s tuberculosis infection rates are reaching crisis proportions, “I’m drawing attention to it,” says Macintyre, “[and saying] ‘okay, given this information we obviously need to increase our targets, but there are other things we need to do as well’.”
The strategy she is drafting breaks the plan of action down into 14 thematic areas. One of them is called “special groups.” These are people who are particularly vulnerable to tuberculosis such as transport workers, people in prison (both wardens and inmates), alcoholics, the elderly, and hard-to-reach populations such as slum dwellers and people in rural areas where extreme poverty leads to poor nutrition and limited access to health care.
Another topic of special concern is the growing number of so-called multi-drug-resistant (MDR) cases of tuberculosis. There have been an estimated 2,000 cases of tuberculosis this year that don’t respond to first- or second-line treatments. This is very disturbing as there were only 390 such cases diagnosed last year and hardly any just three years ago. “It’s really going, it’s got a grip now,” says Macintyre. Treating each of these cases can cost 1.3 million Kenyan Shillings ($16,000) and requires the involvement of the World Health Organization’s green light committee based in Geneva, Switzerland. The growth in such cases is associated with poor treatment or compliance with treatment regimens in early stage tuberculosis. People who are persistent in failing to comply with proper treatment protocols “risk turning into bombs of vectors for the disease,” says Macintyre. “There are a whole slew of issues over non-adherence.”
Kenya’s tuberculosis strategy will take the form of an 80-page document designed to bring coherence to a concerted national push to contain an unfolding crisis. “There are big questions about how the programs are going to be rolled out,” says Macintyre. “It’s not about what the ministry is going to do, it is about what the relationship between the ministries and the civil society will be.” This is why pulling in all the stakeholders during the strategizing stages of the project is so important. “How are the nongovernmental organizations and other missions going to cope with tuberculosis exploding around them? What kind of support are they going to need, what kind of leadership, what kind of capacity, what kind of surveillance systems, what kind of technical support?” asks Macintyre, “I see my role as a link. I am the connector.”
Tulane students are reaping the benefits of having a base of operations and a network of contacts in Kenya. Read The Kenya Connection to find out how.
* MPH student Betsy Charron used her background in photojournalism and commercial photography to augment her practicum, which she completed in Kenya over the summer.