What would have killed Mary Akoth was not the damage tuberculosis was doing to her body in her one-roomed house in Arujo, Homa Bay County.
It was the loneliness, and the economic crutch TB had heaped upon her.
That she, once a fiercely independent person, had to rely on another to bathe her because the pills had broken her body and spirit, was killing her.
Then, she says, community health volunteer Millicent Anyango Boyi happened. “I would not have survived the six months had it not been for her, and it meant a lot to me that she was concerned on a daily basis about whether I had eaten,” she says.
“When I began my treatment, I would get so sick of the joint pains and the exhaustion that I got tired of living but she kept telling me what a long life I had ahead of me,” she says.
From her phone, Millicent called Mary’s daughter to leave her matrimonial home to come help her mother through the sickness.
Millicent says that she had to help Mary finish the dose. She looked too weak to survive the stronger regimen of drug resistant TB she would have had to take had she defaulted on the six-month treatment for her TB, which is not drug resistant.
The volunteer also has to extend this care to HIV-positive patients and expectant mothers who have to be reminded to go for check-ups. New mothers need training on proper nutrition.
For all this work, she gets Sh2,000 a month for all the walking, calling and the emotional toll of handling depressed ill people.
Community health workers are a critical part of the response to TB. According to the World Health Organisation, the proportion of TB patients receiving community-based treatment is 100 per cent in Kenya.
Newsplex shadowed healthcare workers in Migori County which had 1,930 cases of TB and an incidence rate of 180 cases per 100,000 people in 2014 and Homa Bay County which had 2,141 cases and an incident rate of 190 cases per 100,000 people. Both counties rank in the top 20 in TB incidence rate.
At noon, the scorching sun is baking the ground and Grace Olweru’s skin with it. Unable to afford Sh50 for a motorcycle ride, she has been walking from 7a.m.
In the home she is headed to, near Matagaro Primary School in Rongo, lives a 22-year-old mother who is HIV-positive and suffers from TB.
Dedan Aluoch, who is in charge of community health workers in Rongo, told her that the lady had skipped her weekly visit to the clinic. “She has three small children, and the one she is carrying, so if she dies now we will not be mourning just one life,” she says.
In her bag, there are documents for the patients that she feels are “forgetful”. “I have to keep them myself because some of them fall sick often and when we get to the hospital, they cannot be attended to fast enough because they have misplaced their cards, which are used to trace their files,”, she said.
As she passes though the village, many people stop her to exchange pleasantries, and she wears the shoes of a friend and a counsellor.
Twice, she visited a home and asked the children there to come to her house in the evening to get flour for a patient’s family.
Every conversation ends with a casual explanation to Newsplex with a dialogue like: “He is one of my success stories; whenever I see him on his farm my faith in God and science is renewed” Of course, some patients have died, sometimes due to defaulting.
Karoli Migwambo, TB coordinator for Homa Bay County, says that while the rate of defaulting is not as alarming there, the few who drop out of treatment cite inability to keep up with the challenges that come with it, such as reaction to the drugs.
Homa Bay County has the highest HIV prevalence, standing at 25 per cent as at 2014 according to data from National Aids Control Council, and more than 60 per cent of HIV patients in the county have TB.
To ensure that the patients who visit more than 167 treatment centres in the county adhere to their treatment, the county government, in partnership with organisations such as Amref, relies on Millicent and 2,713 volunteers.
In Kisumu, volunteers are sometimes forced to confront greedy spiritual healers who prey on the hopelessness of patients.
LESSONS FROM BRAZIL
Siaya’s use of community health workers and other interventions, as indicated in their data, shows the success of completion of treatment rose from 84 per cent in 2014 to 90 per cent in the first quarter in 2016.
Siaya’s TB coordinator, Mary Wambura, says of volunteers: “They help, but the money they are paid is just for tracing a defaulter. They will not be compensated for persuading a new patient who is coughing to come to the facility and actually turn out to be sick”
The role and effectiveness of community healthcare workers in managing TB has been documented globally.
In 1997, as published in the medical journal Lancet, Bangladesh successfully achieved high rates of case detection and treatment compliance, with a cure rate of at least 85 per cent and very little drop rate ( 3.1 per cent), through the use of community health care.
Another 2008 study published in PubMed showed that nations like Brazil invested in community health workers and injected more money into their training when they noticed there were flaws in their knowledge of TB and control measures.
The National Tuberculosis, Leprosy and Lung Disease Programme (NTLD) reports that there were a total of 81,518 overall cases of TB in 2015, a slight decline from the 90,000 that were in 2014.
Then there is another 20,000 that the Ministry of Health says who suffering from TB but are “missing” but are probably at home taking Piriton for self-diagnosed malaria or hanging around in church, banking halls and schools spreading the bacterium further.
These are very few cases, with subtle public health impact until one calculates the social and economic cost of the disease. It costs the government, and by extension the taxpayer, nearly Sh2million to treat a single case of drug resistant TB, said Dr Enos Masini, the head of NTLD.
This is only the cost of tests to monitor toxicity of the drugs that patient a takes over a period of 20 to 24 months, as well as the actual drugs.
Then the patient is normally too weak to work which affects their overall other household needs like education and emotional wellbeing.
In some severe cases Dr Masini says the patient loses hearing ability, get depressed because family gets isolated from them sometimes to limit infection, so the cost of psychiatric attention has to be factored in.