Volunteers & Visionaries
Kenya’s community health champions
Client: Merck KGaA – GermanyAll along Kenya’s coastal region there are thousands of people helping to eliminate schistosomiasis, an ancient and debilitating neglected tropical disease.
Through a series of community portraits, we highlight a few to celebrate the many who help to do this work.
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Schistosomiasis (also known as snail fever or bilharzia) is a waterborne parasitic infection which affects more than 240 million of the world’s poorest people. Endemic in 78 countries across Africa, Asia and parts of South America, the disease leads to acute health complications and the deaths of an estimated 200,000 people annually.
Infections primarily affect the urinary and intestinal system, causing chronic ill health and in some cases death. Water-based activities such as swimming, washing and fishing make school-age children the most vulnerable, with infection responsible for malnutrition, absenteeism, and impaired intellectual development.
People suffering from persistent and severe schistosomiasis infections are also likely to have chronic irreversible diseases later in life, such as scarring (fibrosis) of the liver, bladder cancer, or kidney failure.
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Schistosomiasis infections occur when people come into contact with water contaminated by the schistosome parasite. These free swimming parasites burrow into the skin and move through the body. They develop into worms, lay eggs and cause damage to the bladder, kidneys and liver.
In areas where sewage and water systems are not fully developed and hygiene is a challenge, eggs from humans easily pass back into watercourses. There they hatch and the parasites burrow into certain types of snails, where they develop further. These parasites then leave the snail as free-swimming organisms in search of humans to infect. And so the cycle continues.
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Treatment is necessary to control schistosomiasis, but treatment alone cannot eliminate it. Long-term behavioural change is also necessary. The World Health Organization is recommending an integrated approach to eliminate schistosomiasis globally. Four of the key components of this strategy are:
Treatment
Providing testing and access to treatment for the communities who need it.Education
Awareness to prevent infection, transmission and re-infection.WASH
Developing sustainable access to Water, Sanitation and Hygiene.Vector control
Measures to control snails that act as intermediary hosts.
Lamu County
'The sea is our road'. Dumila is taken home after working with communities where schistosomiasis is stubbornly holding on. He relies on trusted and experienced pilots like Captain Mohamed to move safely along the coast to do his work.
Dumila has been a healthcare professional for nearly 40 years, and the coordinator for the elimination of neglected tropical diseases since 2012. He operates in Lamu, Kenya’s most northerly coastal county bordering Somalia – an area some choose to avoid.
The healthcare centre Dumila operates from sits on the town’s main thoroughfare looking out to sea, in contrast to Lamu’s narrow streets behind. The centre is near the old town square and is a short walk from the mooring areas, where the town’s supplies come in. The central location keeps Dumila connected to Lamu’s working community, and everybody seems to know who he is.
In the campaign to eliminate schistosomiasis, Dumila has been tireless, but he doesn’t do it alone. He is supported by a small team of healthcare workers and a network of community health volunteers who operate throughout the community.
Water, Sanitation and Hygiene (WASH) in schools and institutions are notably improved across Lamu. Out of the ten wards in the county, four appear to be clear of schistosomiasis. Four are improved, with ongoing education and efforts to increase latrine use and access to safe water continuing - along with treatment when necessary. However, two wards remain challenging because of security concerns in addition to poverty – a toxic mix when trying to eliminate any kind of disease.
‘Dumila is the epitome of consistency and commitment’.
Dr Mbarak Mohamed, CECM Lamu
Health, Sanitation and Environment
Neglected tropical diseases are disproportionately suffered by the poor, a point Dumila is acutely aware of. Poverty and injustice anger him, and his understanding of the challenges many face seems to drive him on. To witness Dumila operate in the community is to understand how deeply he cares, and explains the depth of respect he receives from the people he serves.
Athman Dumila – coordinator for the elimination of neglected tropical diseases in Lamu.
Julius Khonde, volunteer community drug distributer in Lamu, measures Nancy for the correct dose of praziquantel.
Julius Khonde is the community drug distributer in his village of Maisha Masha. He is part of a 12,000 strong volunteer force helping along the coastal region. They are distributing praziquantel to treat communities in areas where schistosomiasis is still a problem.
His village is situated in Lamu county on the mainland a few hours from Lamu Island. It is in an area where Dumila coordinates activities, and Julius is helping out.
Julius’ target of visiting 250 families over five days seemed ambitious until he explained that he was known by almost everybody in his community.
Using a specially marked tape, he measures a person’s height to indicate how many tablets they should be given. The process is quick and efficient.
The praziquantel tablets being distributed are an effective treatment against schistosomiasis. The drug kills the parasite and interferes with transmission, but it doesn’t stop people being re-infected.
Back in Lamu town, volunteer community drug distributers roam the streets visiting homes and businesses. In addition to schistosomiasis, they are targeting soil transmitted helminths, a hook worm that can invade the body through the skin when in contact with infected soil.
Imran is a maritime transport and logistics graduate. He said he had volunteered for the five-day initiative simply because he had some spare time – then added that he was pleased he had, because he was enjoying meeting the community in a way he hadn’t before.
Mohammed has managed the family tailor shop for ten years. He said people in the community were not always aware of their health status, so the initiative was one that he approved of.
Saadia is a local graduate and is on her second day of volunteering. She said the campaign was great for her community and something she wanted to help with.
Aboud is the fruit and vegetable trader who Saadia was registering. He said he appreciated the intervention to further improve the health of the town.
Kuswai (17) and Fahad (14) are outside Lamu’s famed donkey sanctuary in the centre of town. They’re standing with their donkeys, Stylon and Magura, who’ve won first and second place in the Lamu festival donkey race for the past three years – and hope to win again.
When asked about the campaign to eliminate schistosomiasis, the boys said they had heard about it from the healthcare workers and were aware of its importance. Getting teenagers to notice health messages speaks well of the community health programme and its reach in Lamu.
Mombasa County
In Mombasa, schools were one of the focal points for the mass drug administration, targeting areas where schistosomiasis was known to be a problem.
Sofia was originally trained by UNICEF in 1994 to be a community health volunteer. Her experience and long-term commitment to the community health programme makes her perfect for working in schools – a role she said she loved. Mejumaa is a teacher at the Bridge International Academy. Sofia is treating her first in order to reassure the children.
In Mombasa’s suburbs, volunteers operate in pairs. This is because, unlike in the villages, it is difficult to be known by everyone in the area. Rukia has been a registered community health volunteer for one year now, and Hussein for three. Despite the challenges they sometimes face, they both remained committed to helping improve the health of their community. Abdala, who is a mason, and his wife Mwanarusi, said they were grateful for the medicine.
Whilst most of the treatment was distributed house to house, coordinators also focussed on the ferry terminals, a natural pinch-point for people travelling in and out of the city.
Elizabeth Wachira, a senior manager for the port area, said the ferries operated non-stop, transporting 360,000 pedestrians and 6,000 cars daily – pedestrians free of charge.
There were never high expectations about the number of people that could be treated at the ferry terminals, but having visible volunteers around the area was a good way to send a message about the disease, and the campaign to eliminate it.
William is a taxi driver in Mombasa. He had seen the community drug distributors, and had also heard about the campaign from his passengers, so it seemed the strategy was working.
Kwale County
The microscope is Muinde's weapon of choice in the fight against neglected tropical diseases.
Jackson Muinde Mwandi is the coordinator for vector-borne and neglected tropical diseases in Msambweni sub-county, Kwale. He’s based at Msambweni referral hospital and his work informs 400 healthcare workers and 3,000 community health volunteers across the region.
His entire career has been focussed on the elimination of neglected tropical diseases. In the 1990s, Muinde led a team of four, who were considered the fastest and most accurate mosquito dissectors for lymphatic filariasis in Africa. Known as the dream team, they could dissect, stain and identify the development stages of filariasis in over 400 mosquitoes each day. It was an incredible output even by today’s standards.
Laboratory assistants, Jeff and Benson, described Muinde as a fantastic and influential boss – then quickly added that he was also incredibly strict. It seems Muinde’s work ethic has rubbed off on them too. Each month their small laboratory tests over 4,200 samples for schistosomiasis alone.
As well as Muinde’s laboratory work, his community visits, and associations with intervention and research teams, he still goes snail mapping every month. Snails are vectors for schistosomiasis, so knowing where they are and in what quantity provides important information about transmission risks.
It’s hot work, but he does this to compare his findings with the reports he receives from other mapping teams that work in the area. On this occasion, he went with Benson, the next generation of NTD warriors to continue the fight against schistosomiasis.
In areas where snail numbers are considered too high, the water will be treated with a biodegradable molluscicide to reduce the number.
For the past 10 years, Muinde has also been looking at a few plants that seem to have molluscicide properties. Where Polygonum senegalense and similar plants are abundant, snails are not found. Experiments in his laboratory reinforce the finding, but the research is incomplete.
Women of Marigiza Village hold a community health meeting with Muinde. Some are registered community health volunteers – all have their community’s best interests in mind. Muinde has been visiting and working with the same communities for the last 27 years, leading to an extraordinary level of trust.
Every week a community health assistant visits each village to share information about health and the prevention of diseases. Every month, Muinde does a follow-up visit to a few of the villages to make sure they clearly understand the most recent information. If he suspects there are any issues, he works with the Public Health Officer to improve the clarity of the health advice.
‘Every time I meet with Muinde, I learn something new’.
Francis Ndiegi, Director
Msambweni Referral Hospital
25 years ago, people in the area were suffering from chronic schistosomiasis, soil transmitted helminth and malaria infections. Very few of the villagers had toilet facilities or access to safe water.
Today, those diseases have been reduced by 85% through regular health education and health initiatives. Over 90% of homes have at least a rudimentary toilet which complies with basic WHO standards.
There is still much to do, but Muinde believes that with the correct strategies in place, it is possible that schistosomiasis could be eliminated in Kenya by 2030.
Charles Nganga (left), celebrates on hearing that Muinde has been chosen as Merck's NTD hero for 2023. Charles, who has worked with Muinde for 27 years, described him as a true visionary in the NTD world.
Kilifi County
In Bofu Kombeni village, women and children gather to wash clothes in the only plentiful water-source available to them. The village had agreed to help with photography to illustrate how everyday life can lead to the transmission of schistosomiasis.
John Mwagambo, the local coordinator for neglected tropical diseases, had approached the chief and the community to ask for help. Their agreement gives a good insight into the level of trust that exists between coordinators like John and the communities they work with.
Just a short distance away, Salome and Mercy (7 and 8) show how they wash without getting into the water. Fortunately, it is the dry season so infection rates are very low because snails, the vector for schistosomiasis, are rare in summer. However, children generally are more at risk of infection because they spend more time in the water playing with friends.
The fathers of the girls said they were grateful for the initiative to eliminate schistosomiasis. Peter Gande, Mercy’s father, said ‘I would like that we remove this disease. We suffer from it and it affects us’.
The girls go to school and Mercy said she likes to cook. Both girls love football and play for the ‘Black Queens’, Bofu’s all-female football team.
Mwanaidi KweKwe Bakari – Bofu Kombeni village elder. Mwanaidi helped to organise the river-focussed photography, and later introduced a few other activities with a link to schistosomiasis.
Farmers too are in regular contact with the river, collecting water to irrigate their crops. Muta and Mohamed grow okra, maize and amaranth. They farm on the other side of the river, separate from Bofu village but the two sides share a close relationship, which is typical of the area.
Organised village sports are known to reduce the amount of time children play in water, reducing their exposure to schistosomiasis. Mwanaidi explained that Bofu village has two official football teams, Black Queens for the girls and Black Lions for the boys and they often play each other.
Ali, the village football coach, ensures there is a structure to the activities, and includes warm-up sessions and skill-development activities to keep the children engaged. Matches are played for 90 minutes, but divided into three sessions. The first two for the competitive match and the third is a gentler affair allowing younger children to safely join in.
Mwanaidi couldn’t resist pointing out Wema Café, Bofu’s first ever restaurant, and perhaps a sign of the development to come. The affordable food is popular in the community, even the chief occasionally pops in for a meal.
Amina, who owns the restaurant, prepares ugali made from ground maize. Her dish is served with a little meat and boiled cabbage in a simple sauce. Amina said she can serve up to 50 meals a day.
Pauline Sau – Community health volunteer.
William Ngumbao – Community health volunteer.
Pauline Sau and William Ngumbao live in Majengo Mapya village and are community health volunteers. They typically share information about the prevention of disease and are trained to give simple medical care.
Pauline is also a village elder – the first female ever to hold the position in the area. William was a well digger for 22 years until he was forced to retire following an accident. He now uses his experience to advise the community on well-related matters and how to build and maintain simple toilets that comply with World Health Organisation guidelines.
Pauline and William are not alone in what they do. The community health programme operates across Africa, and in Kenya alone over 85,000 people volunteer.
Michael Kazunge is the sub-county coordinator for neglected tropical diseases in Kilifi, and has been a healthcare professional for 36 years. Along with the many other responsibilities a coordinator has, Michael educates communities about neglected tropical diseases, including schistosomiasis.
He’s a gifted and popular communicator. Nevertheless, he relies on good relationships with community health volunteers like Pauline and William to amplify his message.
Access to safe water and basic toilets is essential to the elimination of schistosomiasis. Harusi and her family have access to a community well which provides clean water for all their needs, including her small garden.
She lives in Timboni village and is a member of the inter-village gardening club, where ideas and information for sustainable micro-farming are shared. Her latest project is growing amaranth, a nutritious crop similar to kale or spinach.
Timboni is the neighbouring village to Majengo Mapya, where William lives. In the past he has helped to clean the well in Timboni and still advises on its maintenance.
These types of grass-root connections between villages and communities – through clubs, friendly alliances and health initiatives – are the channels along which good ideas travel. They are also the networks through which disease elimination campaigns are won.
Harusi Kadeng with her granddaughter Mnida.
Eliminating schistosomiasis
The World Health Organization is spearheading the global campaign to eliminate schistosomiasis as a public health concern. To achieve this goal, WHO are working closely with government health ministries and international partners.
One of these partners is German pharmaceutical, Merck KGaA, who have donated over 1.7 billion praziquantel tablets to treat people with schistosomiasis in 47 countries. The partnership between Merck KGaA and WHO has been instrumental in reducing the risk of developing schistosomiasis in sub-Saharan Africa by 60% between 2000-2010 and 2011-2019.
Now in 2023, more gains will have been made and there is a genuine hope that with the correct strategies in place, schistosomiasis can be eliminated by 2030.
Florence Wakesho works for the Kenyan Ministry of Health and is the national coordinator for the elimination of schistosomiasis. She’s almost always working in the field supporting local coordinators, so it was unusual to catch her in the office in Nairobi. Health services in Kenya are devolved, so she collaborates with, rather than directs, the regional coordinators across Kenya. In the coastal region alone, there are six county and 26 sub-county coordinators.
The recent two-stage mass drug administration along the coastal region to combat schistosomiasis perfectly illustrates the collaborative network that she’s a part of. Over a ten day period, six million praziquantel treatments were distributed to communities at risk across 36 wards by 12,000 volunteers. During that time Florence was involved in all manner of activities to support the campaign in the counties where the mass drug administration took place. It was easy to see why the local coordinators are so fond of Florence and appreciate the work she does; she in return affectionately describes them as her warriors in the fight to eliminate schistosomiasis in Kenya.
Acknowledgements
Marcus Perkins and Merck KGaA would like to thank the communities and health authorities along Kenya’s coastal region, for their guidance, permissions and warm welcome in support of this work. We would also like to thank the following people and organisations for their assistance and expertise, without whose help this project would not have been possible.
Florence Wakesho National coordinator for the elimination of schistosomiasis
Dr Mbarak Mohamed CECM Lamu
Athman Dumila NTD coordinator Lamu
Elodie Yard Director Oriole Global Health
John Moss NTD coordinator Kilifi county
John Mwagambo NTD coordinator Kilifi sub-county
Michael Kazunge NTD coordinator Kilifi sub-county
Francis Ndiege Director of Msambweni referral hospital
Jackson Muinde Mwandi VBDCU and NTD coordinator Msambweni sub-county
Ivy Kiru LBx Africa
Elizabeth Wachira Kenya Ports Authority Mombasa
Ministry of Health Division of Vector Born and Neglected Tropical Diseases
Children Investment Fund
Crown Agents
Oriole Global Health
Mombasa Police Department
Kenya Film Classification Board
Muinde with some of the many community health volunteers who help with his work.