Frontline: Primary Health Care and COVID-19 in Kenya

Two weeks after the first Kenyan COVID-19 case was detected (a young women who had returned from the US to Nairobi), the unfamiliar, inverted directionality of this epidemic began to sink in. Contrary to conventional pandemic imaginaries (e.g., Lachenal 2015), this threat was moving from the metropolis to the periphery, from foreigners and middle classes to the urban and rural poor, from city to forest. On 28th March, the Nairobi MP John Kiarie posted a stark warning, widely circulated on social media, which, contradicting the calm tone of the government, predicted harrowing death-tolls and called for incisive measures (leading to his questioning by police the following day). Before culminating with: “Ignore and die!”, he emphasised the key role of “Community Health Volunteers (as) Kenya’s best bet in managing the chaos on the ground that is just about to ensue” and implores his government “please, please, be good to these people, () Arm them with hand-held thermometers for early detections and referrals for the relevant quick medical response. In GoK planning, please set aside monies for a stipend for the CHVs countrywide. They are about to become the frontline in this battle”.  

Veterans who worked as Community Health Workers and Traditional Birth Attendants in the 1990s, some of whom now are Community Health Volunteers (Photo: P. Wenzel Geissler)

The advent of COVID-19 in Kenya found us in the western parts of the country, conducting fieldwork on, respectively, Universal Health Coverage, insurance and the health system, and the residuals and afterlives of 20th century epidemics and anti-epidemic measures. These interests led us to work together with the people who, for almost half a century, have charted the space between health system and potential patients, state and citizenry (framed as ‘community’), professional and lay knowledge, and worker and volunteer, who in Kenya today carry the title of ‘Community Health Volunteer’ (CHV). Following CHVs, we have been working in and around peripheral health facilities near the Ugandan border, attending meetings, visiting households, observing reporting practices, collecting biographies and talking about times past and present.  

In the Kenyan health system, each CHV is responsible for visiting 100 households every month and submitting detailed data on morbidity and vital events, through a reporting chain up to the County. These tasks require much time and CHVs find it hard to complete them, especially since, as they are quick to point out, ‘this is not a main job’ – they must earn alternative incomes. To enable more efficient reporting, NGOs and other organizations have equipped some CHVs with smart phones and designed apps for real-time data entry. However, not all CHVs received such phones, and without maintenance or replacements the Apps get outdated and the phones break down. Hence, many CHVs continue to rely on paper forms for reporting.  

CHVs during an ‘action day’ in anticipation of COVID-19, 27th March 2020, clearing the vegetation around hospital buildings (Photo: Eveline Wasonga)

Created as quintessential ‘middlemen’ (Hunt 1999; though most of them have been and are women) to compensate for the shortcomings of the postcolonial health system, community health workers, as they were called, have remained “in-between” throughout the decades. This ambiguous status is reflected in their remuneration and employment status: except for a brief period when the government envisaged making them into the lowest ranking health personnel, they are de jure ‘volunteers’, without terms of service or contracts, unpaid except for token remuneration and precarious income opportunities through NGO training programmes (Prince & Brown 2016). Today, they receive (irregularly, many of them say) a monthly stipend of between 2000-3000 KSh (ca 20-30 Euro) from the government. In western Kenya, CHVs recently created a union, held together by a WhatsApp group; it is not officially recognised but, until mid-March this year, it held regular meetings to plan for recognition and a proper wage.  

Training of CHWs began in Kenya during the 1970s as church-driven interventions inspired by Alma Ata (Kaseje et al. 1986). Some older CHVs we worked with began as Traditional Birth Attendants in “safe motherhood” programmes. Others were trained as home-based carers, peer counsellors or “defaulter tracers” during the US-funded HIV/AIDS interventions around the millennium. Over this long period, CHVs have evolved from Christian volunteers to ‘Healthy Entrepreneurs’ (one of several organizations promoting a “business model” for community health work, which enables CHVS to earn an income through buying and selling basic commodities), and from proud former TBAs who are no longer allowed to aid delivery at home, through a generation of shrewd NGO-operators with portfolios of training certificates, to young dreadlocked community theatre activists. In group discussions, CHVs joked about the contrast between “analogue and digital CHVs”, but they make a serious point: older CHVS with years of experience, well known and trusted, have been bypassed as younger people are chosen for trainings in data entry using electronic gadgets. What is shared across these differences is their ambiguous positioning: in their villages, CHVs consider themselves ‘role models’ and take pride in being addressed as daktari (doctor), while health professionals treat them as representatives of ´the community’ and gate-keepers to hard-to-reach ‘risk groups´.  

Community Health Assistant (leader of CHVs) ‘sensitizing community’ at a fishing settlement (Photo: Eveline Wasonga)

At the beginning of March, COVID-19 still seemed far away from East Africa, although it dominated the news, creating anxiety as people wondered what would happen if the virus reached Kenya, with its fragile health system. On 4th March, the Ministry of Health began sending messages to all mobile phone numbers with information about the signs and symptoms of COVID-19 and details of a “toll-free line” to call, while County directors of health circulated an adapted infectious disease outbreak protocol and instructed health officers to train health workers on COVID-19 infection prevention, management of cases and surveillance. CHVs, however, were given no information on COVID-19; what they knew about coronavirus, they told us, came from radio and TV, from messages on their phone, and (for some) from WhatsApp, and Facebook, and they had as many questions about it as anyone else.  

This began to change on 20th March, when news broke that a Kenyan priest arriving from Rome, had developed COVID-19, after performing the sacrament and attending a large funeral at a home not far from the rural hospital where we worked. The next morning, at the gate of the hospital, a CHV directed us, like all visitors, to the newly set-up water container with tap and soap, to wash our hands. The sub-county’s disease surveillance officer arrived to provide first training on coronavirus, the hospital in-charge adapted an Ebola screening protocol to identify patients who had fever and cough and had travelled from abroad, while the nursing officer dusted some boxes of protective gear that last year’s Ebola preparedness had left behind, counting herself lucky to be in the risk-area near the Ugandan border and therefore having such equipment. At the county headquarters, meanwhile, health officers were preparing to send CHVS for ´contact tracing´ to the home where the funeral took place. Soon thereafter, CHVs were called for training sessions in which they were told to ´sensitize´ the community about frequent hand-washing, social distancing, and the danger of shaking hands.  

Single-use protective equipment kit received during Ebola-preparedness, revived in anticipation of COVID-19 (Photo: P. Wenzel Geissler)

Forced by an open-ended ban on international flights to leave Kenya on 25th March, this is the point at which we left the CHVs, just as corona finally reached them. From our quarantine in Norway, we’ve been following the CHVs from a transcontinental social distance on WhatsApp. Interspersed with prayers – “Gods intervention highly needed…” – they send us images of their activities, many of which seem to adapt well-rehearsed community health activities to the new challenge. At ‘sensitisation’ meetings, well-dressed MoH staff and CHVs address women at markets and lakeside fishing settlements about handwashing and social distance. CHVs have been employed in slashing and cleaning the hospital compound, an activity with echoes of environmental disease intervention, performed in the past as part of malaria control. Meanwhile, the hospital has cleared a ‘holding area’ for suspected COVID-19 patients awaiting transport (in the 20 year-old ambulance now dedicated to corona) to the (almost completed) isolation ward in the subcounty hospital 30 km away, for at least 14 days isolation.  

Since the case of the travelling priest, the CHVs have also been instructed to help ‘tracing’ the over 200 contacts he associated with, and to identify ‘suspects’ having fever, cough and a history of travel from overseas. If they find a suspect, they should call a national number to organise screening and if necessary internment. Terms such as ‘suspects’ and ‘screening’ evoke histories of late colonial sleeping sickness control in the area, especially since the planned isolation ward is in the same place as the 1950s sleeping sickness camp. The problem with identifying cases, CHVs tell us, is that “people in the community fear being taken as suspects”. People are avoiding hospitals, and some refuse the usual visits by CHVs to their homes, fearful of both being quarantined and the loss of income this would entail. Being on the frontline between government and community, CHVs are positioned ambiguously between them, respected by villagers for bringing information, while feared for their authority to enforce hospitalisation and suspected of bringing the infection from the health facility, other patients, or the towns where they live.  

Volunteers during CHV action day, spraying the newly designated ‘holding area’ of the hospital (Photo: Eveline Wasonga)

While initially feeling side-lined in the COVID-19 response and attendant opportunities for training and compensation (“we were at the frontlines of combating cholera cases last year, it was us who did all that work and now they are ignoring us”), CHVs are increasing anxious about their own health and that of their families, as well as the loss of income. Their work by its nature involves mobility and social contact, and some have other health conditions like HIV, diabetes or hypertension. Health officers and health workers share these concerns – as one county official told us, “With our health system, if we get this infection we are sure to die”. While (not enough) surgical masks and gloves have been sent to the country´s referral hospitals, CHVs (like most health workers) have no protection. Sub-county hospitals and health centres have been issued with (some) hand sanitizer, soap, chlorine, and extra water containers, but this does not help CHVs walking around households, who must buy their own.  

In addition to the threat from potentially hostile villagers and from the virus itself, CHVs also share the massive economic impact of the lock-up with everybody else who lives off a precarious income without regular wage (over 80% of Kenyans have no formal, salaried jobs). As one wrote, “In addition, we have another fear, our income is from hand to mouth…If it can be decided that we must be locked indoors, (the) majority of us will sleep hungry. We fear the lock down…” Further government regulations, introduced on 22nd March, are creating considerable anxiety. In addition to the closure of schools, colleges, and the country´s borders (announced mid-March), Kenyans have been told to stay at home, police have cleared the streets and roadsides of petty traders, public transport has been curtailed, and since 27th March, a night-time curfew has been enforced by police. Like everyone else, CHVs fear police officers and their violence in enforcing the curfew. Unlike doctors and nurses, they have no special “essential workers” badge, which could protect them. Our messaging and conversations on WhatsApp have been cut short as people hurry home. “The brutality is too much. Last time I was hit on the forehead after work!”, one CHV messaged us, “let me make it home safely”.  

Works Cited

Hunt, N. R. (1999). A Colonial Lexicon. Of Birth Ritual, Medicalisation, and Mobility in the Congo. Durham & London, Duke UP.

Kaseje, D., Spencer, H.C. &  E. Sempebwa (1987). Characteristics and functions of community health workers in: Saraddi, Kenya, Annals of Tropical Medicine & Parasitology 81:sup1, 56-66, DOI: 10.1080/00034983.1987.11812189

Lachenal, G. (2015). Lessons in Medical Nihilism: Virus Hunters, Neoliberalism and the AIDS Pandemic in Cameroon. Para-States and Medical Science: Making African Global Health. P. W. Geissler. Durham, Duke University Press103-141.

Prince, R.J & Brown, H. (2016). The Politics and Ethics of Voluntary Labour in Africa. In Volunteer Economies, edited by Ruth Prince and Hannah Brown. Oxford: James Currey.

P. Wenzel Geissler teaches social anthropology at the University of Oslo. With Lachenal, Manton, Tousignant and other scholars and artists, he published Traces of the Future (2017). With Ruth Prince, he recently began studying the remains and afterlives of the East African AIDS epidemic, revisiting their earlier book on the times of AIDS in Kenya, The Land Is Dying (2010). 

Ruth J. Prince is associate professor in medical anthropology at the University of Oslo, where she currently holds a European Research Council Starting Grant for “Universal Health Coverage and the Public Good in Africa”.    

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