Connecting Diagnostics in Samburu

by Tobias Rinke de Wit

The ‘Yellow Wings’ Cessna looks like a half demolished nineteen sixties motorbike equipped with far too tiny wings remotely supposed to keep us up in the ultrathin Kenyan air. My WhatsApp reveals a daunting message from my wife, after she learned the pilot is German: ‘tell him some jokes; – that might distract him’. Our family sense of humor.

Anyway, after showing the pilot my missionary KLM status and claiming (in vain) compensatory Flying Blue miles for supposedly high-risk single engine propeller flights, I find myself in this 3-seater, together with colleague Henk Smits from the Royal Tropical Institute. The plane (or whatever it should be called) rattles and shakes graciously swinging into mostly unpredictable directions. Even the slightest movement of myself on my small seat results in a significant turbulence experience.

We are on our way to Samburu, one and a half hour flying north of Nairobi, Kenya. At 8,500 feet we shave the mountain heads covered with bamboo, circle around an incredible waterfall and inspect a group of illegal loggers, setting fire to the bushes. After the mountains we drop into the arid plains of Northern Kenia. Later we learn that there are places that did not see rain over the past two years.


Almost dried lake close to the town of Maralal

Landing on a dirt-road airstrip, we are immediately surrounded by local Samburu. In one hand a machete, in the other an occasional Kalashnikov or blackjack. Ears are conveniently elongated to carry kilos of metal, beads, bones and embroideries.

Moses, the local representative of PharmAccess partner AMREF collects us from the airstrip and after 30 minutes shaking our intestines, livers and spleens on an unadulterated roller-coaster African dirt road we arrive in the hospital of Maralal. This is the referral place for the entire Samburu population (260,000 people). We meet the one and only surgeon on the compound, who seems to take a half-way operation smoke-break in his characteristic green suit.

We are chasing brucella, a nasty bacterium that is transmitted through non-boiled milk and blood. Brucella causes abortions with goats, sheep and cows. In humans brucella causes fever, malaise, sweats, headache, the typical ‘atypical symptoms’ that make life difficult for doctors and nurses to diagnose.

However, when brucellosis settles in and becomes chronic, it cause more severe problems: arthritis, endocarditis, swelling of liver, spleen, scrotum, chronic fatigue, depression and neurologic symptoms. The key in preventing this suffering and keeping people at work is: proper and timely diagnosis. Quite recently, Henk Smits at the Royal Tropical Institute has developed a rapid test for brucella that is highly specific and sensitive and can help detecting the disease at an early stage. After diagnosis, treatment with antibiotics cures the patients. These antibiotics are not expensive and can usually be obtained easily (see box file).

Our mission in Samburu is to assess the feasibility of establishing a Connected Diagnostics Project, in this case: to diagnose and create mobile health wallets for brucellosis and malaria for the Samburu population. Even though we are only two days around, it is clear to us there are ample opportunities. First of all, since 2014 PharmAccess is already involved with a maternal health project in this area, in collaboration with AMREF and the M-Pesa Foundation. This project, skillfully managed by our colleague Doriane Nzorubara, has greatly contributed not only to better health for (pregnant) women, but also to the installation of Safaricom mobile phone masts and linkage of local ambulances to the M-Pesa system. Around the town of Maralal, everybody is basically connected. Second, we notice a clear presence of brucella and malaria in the population: not only from statistics of the hospital, but also by talking with the local farmers we find out that cattle milk is not boiled before human consumption, it is often mixed with blood into soups. Moreover, there are abortions with the sheep and goat and the placenta is thrown to the dogs. We conclude there are all kinds of ways in which brucellosis can be transmitted in this population.

At the slaughterhouse, we stop and look in awe: boys are arriving on their motorbikes with a sheep or goat loosely draped between them. Seconds after they enter the slaughterhouse, they leave again with the uncoated animals. Heads and feet are ‘recycled’ by local women first by roasting, than into the soup. All ingredients for transmission of brucellosis (and other bugs) are there….

The Maralal slaughterhouse                         

Fresh blood to be mixed with milk

 The sheep heads are roasted for the soup

Back at the AMREF office we make arrangements with nurse Moses, who expresses his enthusiasm to work on this project. To celebrate, we have our lunch on bones of sheep and goats in the local pub. And back we are flying with our impeccable pilot.

In Nairobi we discuss particulars with Michiel Slootweg from CarePay and with Max Schiff, the representative of FIO company in Nairobi. We will use the FIO readers to upload the brucellosis and malaria diagnostic test results into the cloud. These uploads will trigger a mobile health wallet for these diseases via CarePay. Cees Hesp leads the technicalities in this process. The plan is to prove that ‘Connected Diagnostics’ work, even in remote settings. We intend to document this proof-of-principle, write a (scientific) paper, a lay-report and make a 10 minutes video of the process. It is hoped that in particular the video will convince payers that this type of bottom-up payment through mobile health wallets, guided by high quality affordable mobile diagnostics, is the future. The dream is to roll out such models of healthcare financing and implementation in the more than 1,300 Kenyan healthcare providers that PharmAccess has connected to CarePay. In the future, the scope and scale of such projects can be further expanded by addressing other diseases (typhoid, hepatitis, HIV, leptospirosis, etc.) and connecting other countries (Tanzania, Uganda, etc.).

On behalf of Henk Smits I would like to thank the PharmAccess Nairobi office for excellent organization of this adventurous assessment visit. The proposal for this project was submitted to the Achmea Foundation.