When global health goes local: Tackling infectious diseases and antimicrobial resistance in Kenya

Antibiotics have helped treat millions of people around the world, but they are losing their efficacy at an alarming rate. At the Moi Teaching and Referral Hospital, or MTRH, in Eldoret, Kenya, some patients are presenting with infections that are increasingly harder to treat, while others no longer have a cure.

“There are patients dying from infections that can't be treated with antibiotics,” said Dr. Adrian Gardner, a physician and executive field director of the Academic Model Providing Access to Healthcare, or AMPATH, Consortium in Kenya. “We don’t really know how big the scope of the problem is at this point.”

Infectious diseases are responsible for an estimated 8.4 million deaths annually across the globe and are a leading cause of death worldwide, particularly among young children and marginalized populations in underserved communities, often perpetuating the cycle of poverty.

Antimicrobial resistance — when microorganisms change in ways that render the medications used to cure the infections they cause ineffective — is now a global health emergency putting mounting pressure on oftentimes already-vulnerable health systems. It hinders not just drug-based therapies, but other health interventions that rely on the ability to control infections — even common surgeries or hospital stays can be fatal in a post-antimicrobial world.

By 2050, it is estimated that 10 million people will die annually from drug-resistant infections, causing $100 trillion in economic losses if efforts are not drastically scaled up. Resistance to pathogens that are responsible for tuberculosis, malaria, and HIV has been observed around the world, as well as to those responsible for influenza, typhoid, diarrhea, and a host of others.

The causes of antimicrobial resistance are complex and more difficult to control in countries with weaker health systems. Gardner said pharmacies in Kenya sometimes run out of stock and substitute antibiotics. Patients also risk being provided substandard medicines, a common occurrence across sub-Saharan Africa. The World Health Organization estimates that 1 in 10 medical products in low- and middle-income countries are substandard or falsified.

What’s more, overuse and misuse of antibiotics across the food chain contributes to the transmission of resistant bacteria from food-producing animals to humans, leading to an increase in drug-resistant foodborne pathogens.

In 2015, WHO endorsed a Global Action Plan to coordinate a response to AMR, and world leaders in 2016 committed to combating AMR in an unprecedented, high-level U.N. General Assembly meeting. The G-20, the African Union, and others have followed suit, placing AMR at the top of international agendas.

However, translating this commitment to local action has been weak, with LMICs showing particularly slower progress. Many still lack their own national action plans, and a survey conducted among health facilities in Africa revealed that only 14% had antibiotic stewardship activities — designed to promote the appropriate use of antibiotics — in place.

The need for a localized approach

Addressing AMR requires a multipronged approach focusing on limiting the spread of infectious diseases, developing new drugs, improving diagnostic capabilities, ensuring appropriate use of existing antibiotics, and strengthening the surveillance systems needed to inform real-time decision-making. Strong, capable health systems and policy reform will form the backbone of any efforts.

In Kenya, a new program run by AMPATH and supported by The Pfizer Foundation, among other partners, is targeting AMR on multiple fronts, with the goal of ultimately providing evidence that will help strengthen the country’s capacity to fight infectious diseases. AMPATH is a partnership between MTRH, Moi University’s College of Health Sciences, Kenya’s Ministry of Health, and a consortium of North American universities. For nearly 30 years, it has been implementing care, training, and research programs, including Kenya’s first PEPFAR-funded antiretroviral therapy program.

“It's all about the health care systems and really helping our partners think through what are the interventions that are going to be most effective,” said Darren Back, vice president of health investments for Pfizer Global Health and Patient Access, who also helps manage The Pfizer Foundation’s portfolio of grants and programs.

“By focusing our partnerships and resources on improving the prevention, diagnosis, and treatment of infectious diseases, we hope that we can also tackle some of the barriers that are most relevant for addressing antimicrobial resistance,” Back added.

This new program with AMPATH is part of The Pfizer Foundation’s larger portfolio of global health investments. In 2016, The Pfizer Foundation launched the Global Health Innovation Grants, or GHIG, program, a flagship initiative combining funding with technical support, in collaboration with Innovations in Healthcare, a nonprofit organization hosted by Duke University. Building on more than three years of success and ongoing investments, the GHIG program in August of this year invested an additional $2 million in 20 organizations working to combat infectious diseases across 12 LMICs.

This investment is part of Pfizer’s larger, multisectoral strategy to fight infectious diseases and AMR, which also includes multiple investments from Pfizer Inc., such as deploying Pfizer colleagues in countries to leverage their skills with partner organizations to help strengthen local capacities and overcome critical bottlenecks, Back explained.

Kenya has already achieved important progress in tackling AMR. It is 1 of 11 African countries that has developed a national action plan on AMR. However, it is still facing several significant challenges. Among them are the burden of infectious diseases, lack of trust in the medical system, and inadequate access to quality drugs, according to the Global Antibiotic Resistance Partnership.

Strengthening Kenya’s ability to control infections has become even more urgent as of late. The ongoing Ebola epidemic in the Democratic Republic of the Congo has put a spotlight on the need for greater investments in preparedness and surveillance systems, and has led countries in the region to increase their efforts to diagnose and treat infections. But pouring funds into vaccines and laboratories is only part of the solution, Gardner explained.

“What actually drove the spread of the Ebola epidemic at a local level is really a lack of trust in the health system,” he said. “We see that over and over again in Kenya. If the drugs are out of stock, or there's no electricity, or the maternal ward has no delivery packs and so you have to bring your own, all those things create lack of trust in the health system … It leads to home deliveries, or going to the pharmacy and buying antibiotics directly because you know the clinician at the facility is not going to be there.”

AMPATH intends to leverage its expertise to tackle AMR in Kenya, helping the country turn its action plan into practice. And it hopes that its experience might also help to inform similar efforts in other countries. Over the next three years, it will implement several activities within the health system at all levels of care from community health centers and dispensaries to MTRH’s national hospital.

“What the country needs is not just more national-level policy documents, which Kenya actually has, but also models of how this can work at the local level,” Gardner explained. “We’re trying to pilot innovative models in health delivery that are successful and can be replicated across different facilities and perhaps different counties within Kenya.”

Stronger health systems

The project aims to improve MTRH’s microbiology capacity. The hospital currently lacks the facilities, equipment, and trained staff necessary to run all the necessary microbiology tests, meaning doctors must sometimes treat patients without accurate diagnoses. This increases the risk of prescribing an inadequate drug, Gardner explained. With more lab capacity, the hospital will be able to generate more data on infections and AMR, and in turn, help the government understand how prevalent the problem is.

AMPATH will also work with staff to understand the technical and behavioral barriers to antimicrobial stewardship, and to develop good practices on antibiotics use among staff. The hope is to build a culture where doctors systematically rely on lab tests to prescribe antimicrobials, Gardner said. And it will work to improve the prevention and control of infectious diseases within the hospital.

Because AMPATH works closely with the Ministry of Health, and because MTRH is a public hospital, there are many opportunities for knowledge transfers to take place within the Kenyan health system, and to build capacity at a national level, Back explained. AMPATH also has well-established research partnerships that are conducive to producing rigorous evidence and data on the program’s outcome.

“The Pfizer Foundation looks to form partnerships that generate evidence that's not only valuable, but that is also going to be relevant to governments, so that they can leverage evidence-based data to support their own health system strengthening activities,” Back said. “The AMPATH partnership is an excellent example of this approach.”

Editor’s note: The Pfizer Foundation is a charitable organization established by Pfizer Inc. It is a separate legal entity from Pfizer Inc. with distinct legal restrictions.