Public Health in the Developing World: A Homecoming Perspective

leon-espira I spent my Christmas break in Kenya and after not being home for 13 years, it was quite the experience. I would like to share my some my impressions on being back “home” with you guys and also talk about how I see the practice of public health playing out in the developing world.

First off, there is a sense of optimism about Africa these days and I was excited to see for myself if this was justified. From first impressions, there is no doubt that materially Kenya has gotten richer and has fully embraced the modern consumerism. You can see it on the roads- the number of cars has more than doubled since the last time I was there. Mall culture has also been fully embraced, with new malls being built all over Nairobi. Whether this is for the better, reflecting the maturity of Kenya as a society and an economy and whether the spending binge by the emerging middle class is sustainable is open to question. But middle class and disposable income are fluid terms- being middle class in Kenya is not the same as being middle class in America. The emerging middle class in Kenya seems to be more consumption focused. Being the most sophisticated economy in the region, Kenya has managed to build a credit and financial sector that drives demand by a nascent middle class for the short term, but long term prospects are more uncertain in my opinion. But l digress, after all this blog should be about public health and not about the economics of globalization.

I spent my break in western Kenya, and what struck me right away is how young everyone is- my age or younger. Whether this will translate into a demographic dividend or curse, is what Kenya will to grapple with over the next generations. Economically, the region hasn’t changed much since the last time I was home. It is still essentially agrarian and the few industries that exist are mostly for the processing of agricultural produce- dominated by sugar mills. It is also obvious that the agricultural system is coming under increasing stress since it has essentially remained focused on the production of a low value, high starch staple- maize and with each passing generation there is less land on which to grow it.  A by-product of this econo-agarian system is also a crisis of energy utilization. Most of rural Kenya is trapped on the bottom rungs of the energy utilization ladder- wholly dependent on biomass for its energy needs. There are no resources left to devote to climbing up the ladder because the agricultural system is so labor intensive and yet so low value that it doesn’t generate enough surplus to drive real societal growth.

I realize that I am painting a rather bleak picture and may be coming across as a nay-sayer. But I want also want to point out that there have been genuine successes in western Kenya especially in public health- hence the demographics. The availability of ARVs seems to have stayed HIV/AIDS. Anecdotal evidence suggests a prevalence of about 10% (still unacceptably high, but a lot better than what it was in the 90’s with 20% or more infected) and child mortality has definitely declined. Now one of the major challenges will be handling the after effects of HIV/AIDS for example the spike in childhood TB cases, of which a lot are extra-pulmonary making them harder to detect and treat.

What I see in western Kenya is the need to look at development solutions as system challenges. One cannot simply concentrate on agriculture or child health in isolation. If successes are not to be transient, then an appreciation of the wider system is needed. As resources become scarcer, these systemic links will be even more crucial since it won’t be as easy to shift systemic flows anymore. For example, improvements in child health that result in a growing population cannot simply be balanced by bringing more land under cultivation. This is a luxury that we are rapidly running out of.  I would therefore challenge everyone in public health and especially those in global and international health to start thinking systemically. We all hope to have a positive impact and the more interested we are in the world beyond what we are trained in, the better we will understand what we are trying to do and the more likely that our work will have a lasting, positive impact.

All the best for 2014 everyone and let me end with a picture from my first day back in Kenya when I climbed Mt Longonot, just to give you guys an idea of why Kenya is a rather special place.

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