The shiny metal cabinet in Sarah Helms’ sixth grade classroom is full of necessary supplies — not paper and pencils, but personal care products. (Credit: Sarah Helms)
The locked metal cabinet doesn’t look amiss in Sarah Helms’ sixth grade classroom, with its bright yellow walls and green plastic stationery caddies. But rather than pencils, pens or binder paper, its shelves hold bottles of shampoo and body wash, soap, deodorant, toothpaste, toothbrushes, cotton swabs, sanitary pads and tampons.
For the past three school years, Helms, an English teacher at Horace Maynard Middle School in Maynardville, Tennessee, has stocked a “hygiene closet” with personal care items donated for students from low-income families by fellow teachers, current and former Horace Maynard parents, and members of the community. Helms uses cash donations to buy supplies at the dollar store. Her parents gave her the cabinet.
“I noticed certain kids being picked on for not being well groomed, and I felt that many children were just too shy to go to an adult and ask for help with the items they needed,” Helms told HuffPost. She could see how it eroded their self-esteem when their classmates commented on their appearance or body odor.
Once a month, Helms pulls toothpaste, tampons and other toiletries — including “random donations,” such as hairbrushes, combs, body spray and lip balm — from the hygiene cabinet and packs them into plastic grocery bags for 14 girls and 17 boys.
“A huge blessing” is how one Horace Maynard parent I contacted described the hygiene closet at her son’s school. Helms reached out to this single mom (she asked to remain anonymous) at the start of the school year to see whether her son would be interested in receiving a hygiene pack. She said yes. Her son’s monthly bag includes shampoo, deodorant, toothpaste, razors and cologne.
Closet program increase highlights poverty gap
Horace Maynard’s hygiene closet is just one of the thousands of similar programs in public elementary, middle and high schools across the U.S., according to data from DonorsChoose.org, an online giving platform where public school teachers can ask for funds for their classroom needs. The site has seen requests for hygiene and personal care products mushroom, from just one in 2002 to 1,789 last year. Nearly two-thirds of requests come from schools in urban areas, and they are particularly common among schools where three-quarters of students or more are from low-income households.
Over a third of pupils at Horace Maynard are eligible to receive a free or reduced-priced lunch, and some benefit from the school district’s donation-supplied food program, which provides students a weekly bag of groceries to take home to their families.
Helms sends her students home with hygiene bags the Friday before the end of the month. “This is usually when items are needed most because those families who are on food stamps are low on money for other things like hygiene items,” she explained.
Lisa Greenig, a teacher at Fairfield Middle School in southeast Iowa, said the idea for her school’s hygiene closet came about after a discussion with fellow teachers about SNAP restrictions. “Hygiene items can be expensive. Considering 50% of our students live under federal poverty guidelines, I decided to go public with the idea,” she said. “The community embraced the idea and has been very generous to help stock the closet,” which the school started in January.
The hygiene closet at Iowa’s Fairfield Middle School, where half of the students live below the poverty line. (Credit: Lisa Greenig)
So far, about 24 families have signed up ― parents and guardians of students just have to complete a registration form to receive items from the hygiene closet. “We did not want to risk offending anyone by offering a bag of products without them submitting a request,” Greenig said. “At no time do we want families to feel embarrassed about using the closet.”
Greenig hopes more families, often reluctant to ask for help, will access the program once they realize how private distribution is. “Re-orders typically come through email directly to me. I pack a bag and quietly place the items in the student’s locker. Refills fit in student backpacks so they can be carried home.” With support from local businesses, such at the Hy-Vee grocery store, and backing from school Superintendent Laurie Noll and school board member Jennifer Anderson, Greenig says the district has plans to expand the program to the high school and two elementary schools.
School attendance and self esteem at risk
Other programs are a direct response to changing family circumstances, such as homelessness. “We’ve had an increase in families losing their housing, doubled or even tripled up in a household,” said Stephanie Martinez, program director of student services for the Jefferson Elementary School District in California’s Bay Area. “It’s been pretty drastic and very challenging [for students] if they’ve lost their housing or have a long commute into school.” Martinez is planning a hygiene pack program for the new school year to help students from the 100-plus families in the district living in transitional housing or shelters.
Lack of access to hygiene products can have a negative effect on the lives of children and teens, said Aleta Angelosante, a child psychologist at the Child Study Center at New York University’s Langone Health: “If you are outwardly having difficulties with hygiene, it can certainly lead to at best being more neglected or ignored, at worst being pointed out and bullied in some way.”
North Carolina nonprofit BackPack Beginnings set up a personal care pantry in its Greensboro headquarters about 18 months ago to help schools in Guilford County provide products to students.“We have heard stories concerning the way it impacts self-esteem and the fact that some are skipping school because they are embarrassed by their own hygiene,” said BPB Executive Director Parker White.
Nearly 1 in 5 girls in the U.S., for example, have either left school early or missed school entirely because they did not have access to sanitary products. “Many have heard of teachers buying food for their students, but fewer people hear about them buying hygiene products. Our teachers are underpaid as is, and we want to take this burden off their plate.”
According to a survey of teachers who use DonorsChoose.org to make funding requests, 84% in the highest poverty schools have purchased essentials such as hygiene products for their students. Of those, 63% report spending more than $100 per year on these items.
Parker said about two dozen schools currently access the BPB pantry program, helping hundreds of students across the district.
Fighting for hygiene equity in schools
While programs led and funded by nonprofits and teachers are to be celebrated, hygiene equity campaigners say this issue calls for state intervention. Most hygiene items are taxed under state laws; some, such as dandruff shampoo and chapstick, are not. Some progress has been made around access to sanitary products and several states, including Nevada and Florida, have removed the so-called “tampon tax.” California’s Gov. Gavin Newsom is unveiling a budget plan this week that would drop sales taxes on menstrual products.
But as long as government programs such as SNAP continue to put toothpaste and tampons on the same list of prohibited purchases as tobacco and beer, teachers, parents and local communities will likely still provide such items for low-income students.
Helms said the hygiene closet program had show her just how much of a lifeline this and other assistance schemes are for many students in her community. As the Horace Maynard mother I spoke to told me, “The closet at my son’s school has helped us tremendously. The products that are sent home are used by all my kids. It’s really a very thoughtful thing to do to help make sure the kids feel loved. I would tell everyone that has donated thank you. A million times over, thank you.”
Teachers like Sarah are being forced to leave the Bay Area because they can’t afford the outlandish housing costs
A few years ago, Sarah was living in a drafty garage belonging to one of her friends. Despite being a smart, highly qualified teacher to sixth- and seventh-graders at a public middle school not far from San Francisco’s international airport, she simply could not afford to live anywhere else in the city.
San Francisco is facing an unprecedented housing affordability crisis. That was the conclusion of an analysis published in July by the city’s planning department documenting the huge challenge facing the city and the wider Bay Area. Rapidly rising rents and soaring property values, combined with high construction costs and prohibitive zoning policies, have stymied the “missing middle” housing options needed for public sector employees like Sarah, who earn too much to qualify for low-income housing, but not enough to afford the Bay Area’s often outlandish market rates.
While teachers may be invaluable to society, their pay and working conditions are deteriorating as housing costs rise. On Monday, Los Angeles public school teachers began their first strike in 30 years after more than a year of failed negotiations over issues that include pay.
“It’s so important for our public servants to be able to live in their communities,” says Kristy Wang, community planning policy director at the nonprofit San Francisco Bay Area Planning and Urban Research Association, or SPUR. “But we live in such a high-cost housing market that it’s really difficult for them to do that because they just don’t make enough.”
Sarah (who asked that her real name not be published to protect her privacy) is a 32-year-old originally from the East Coast who moved to the Bay Area after gaining her master’s degree and teaching credential in Southern California. In 2011, she was living with her boyfriend and their young daughter on the outskirts of San Francisco in a one-bedroom apartment that cost around $1,500 a month. When she and her boyfriend split up four years later, the market rate for a similar apartment was at least $2,400. As a newly qualified teacher earning $2,700 a month, she just couldn’t make her budget stretch that much.
“Basically, we had nowhere to live,” she says. Then her best friend, also a single mom and struggling to afford her duplex rent, suggested that Sarah move in. “My daughter shared a room with my friend’s son — they’re the same age, went to preschool together and know each other well,” Sarah says. “And I lived in her garage for a year.”
Listening to Sarah’s matter-of-fact account of how she bought carpet and space heaters to make her new sleeping quarters more comfortable, the rationale is compelling. Her rent was now $1,300 a month, and sharing grocery shopping with her friend also cut costs.
But, she says, the situation was ridiculous. The poorly insulated garage was stifling hot in summer, uncomfortably cold in winter, and lacked direct access to the duplex, which meant going outside at night to reach the bathroom. The move added up to 40 minutes each way to her daily commute. And she had to buy a baby monitor so that her daughter could hear her mom’s voice before she fell asleep.
“It’s really upsetting to be a working adult who can’t even afford a one-bedroom apartment by myself,” she says. “That makes me very angry.”
The Bay Area’s affordable housing crisis has made stories like Sarah’s shockingly common. Assuming a household spends no more than 30 percent of income on rent, it would need to earn $180,000 a year to be able to afford the median rent in the city, according to the planning department’s analysis published last summer. In San Francisco, the starting salary for a credentialed teacher is $55,461.
Two-thirds of teachers spend more than 30 percent of their income on rent, according to a 2018 survey by Stanford University for San Francisco Unified School District. Of those, 14.7 percent say rent accounts for more than half their income. Annual teacher turnover is around 12 percent, which translates to the district having to fill an average of 400 classroom vacancies each school year. Housing affordability is the biggest reason given for teachers leaving, according to Daniel Menezes, SFUSD’s chief human resources officer.
“Educator turnover hurts a school because children need to experience safety and stability,” says Elaine Merriweather, executive vice president of the United Educators of San Francisco union. “Educators develop relationships with students that really help to support their growth and learning.”
Collective bargaining and the parcel tax approved last June ― which will provide teachers with a 7 percent wage rise over the next two decades funded by a $298 annual tax on San Francisco property owners ― have increased basic teacher salaries by over a third since 2014, according to SFUSD’s Menezes. But, he says, the costly housing market means these pay increases aren’t enough to attract and retain educators, particularly those just starting out or who have a family.
“Every year, it is getting harder and harder to go out to national universities and convince a teacher to come to San Francisco because of the affordability issue,” Menezes says.
To address the crisis, SFUSD has partnered with the city and the teachers union to build its first teacher housing complex, with occupancy expected in 2022. The Francis Scott Key development in San Francisco’s Outer Sunset neighborhood in the west of the city will convert a surplus school district site into 130 apartments, costing from around $1,600 for a studio to $2,300 for a three-bedroom.
BAR ARCHITECTS FOR MIDPEN HOUSING An artist’s impression of the Francis Scott Key development in the Outer Sunset neighborhood of San Francisco.
“We’ll have teachers at the higher end of that scale and we’ll have para-educators — special needs teachers and assistants in the classroom — who earn less,” says Kate Hartley, director of the Mayor’s Office of Housing and Community Development. “We’re really excited about being able to serve that wide range of school employees.”
While Sarah welcomes the idea of dedicated housing for teachers, she says she wouldn’t be able to save any money or afford a house if she stayed in the Bay Area and had to pay those kind of rents.
To genuinely address the teacher housing crisis, the Bay Area needs protections for existing tenants and a deluge of new housing units, says Sonja Trauss, founder of the San Francisco Bay Area Renters’ Federation.
Trauss, who was a high school math teacher in the East Bay, quit her job a few years back when housing and commuting costs became too much for her to afford. Since then, she has campaigned for higher-density zoning.
“Too much of the city is zoned for low-density housing in a place that is incredibly in demand,” Trauss told HuffPost. “It’s not just San Francisco, but all over the Bay Area.”
Trauss has also fought against homeowners who block development to preserve neighborhood character. “The situation we have now is that people who already have their homes really don’t care if there’s a [housing] shortage”, she says. “Their feeling is that allowing the city to grow would change neighborhood character … But these are the people that the city needs to survive.”
In a recent example of the kind of Bay Area nimbyism Trauss has called out, more than 6,500 people signed a petition against proposals to build low-cost teacher housing in the wealthy Almaden Valley neighborhood of San Jose. San Jose Unified, the largest school district in the South Bay and a good one-hour drive from San Francisco, is considering converting eight schools with aging buildings or declining enrollment into affordable teacher housing. The plans, however, have attracted criticism from residents.
“The plan will definitely be a game changer for a lot of people and would really help me out because housing will be low market rate, which would allow me to have more of a long-term outlook in the district,” says Mike Rodriguez, a 12th-grade math and economics teacher at Jefferson Union’s Thornton High School.
Rodriguez, 30, has a master’s degree and has been teaching for four years. He makes $50,000 a year and has $100,000 of student debt. He drives for Uber for at least two hours each day to boost his income, lives with three others and looks forward to the day when he might not need to rent a room in a shared apartment.
The region’s teacher housing crisis needs both investment and political will, says Wang from SPUR. While there is no magic bullet, she adds, European models such as Germany’s baugruppen co-housing communities and Vienna’s affordable social housing, which offer city-based, lower-cost accommodation with shared facilities, could provide solutions for middle-income earners such as teachers and other public-sector workers.
For Sarah, change isn’t coming quickly enough. For the last two years, she has been living with her parents and her daughter in Redwood City, a 30-minute commute to her current school. Once the school year ends, she plans to move to a more affordable city like Sacramento.
“It would have been nice if there had been rent control and better salaries,” she says. “I do love teaching here, but I am being driven out.”
By 2030, carbon dioxide emissions caused by humans need to fall by about 45% from 2010 levels, reaching ‘net zero’ around 2050, says the report. Remaining emissions would need to be balanced by removing CO2 from the atmosphere, for example through reforestation and improved land management.
Big data — whether historical or real-time — can also help us tackle the problem, for example by locating harmful emissions or identifying pressure points along the supply chain. This transformative change in data capabilities is an example of what the World Economic Forum refers to as the Fourth Industrial Revolution (4IR).
When California Governor Jerry Brown announced in September that the US state would be launching “its own damn satellite” to monitor the effects of climate change, his promise was bold: an initiative to help governments, businesses and landowners to pinpoint — and stop — destructive emissions “with unprecedented precision, on a scale that’s never been done before”.
Launched against a backdrop of the Trump administration’s withdrawal from the Paris Agreement, California is taking local action to a global problem in the absence of federal leadership. Working with San Francisco-based Earth imaging company, Planet Labs, the state will develop and eventually launch a satellite capable of detecting the “point source” of climate pollutants, monitoring leaks and other anomalies at specific locations.
The satellite, an initiative of the California Air Resources Board, will complement project partner Environmental Defense Fund’s MethaneSAT, scheduled for launch in 2021. The latter will provide broader, more frequent coverage, quantifying emissions from oil and gas fields producing at least 80% of global output roughly every four days.
Individually, the projects will generate important data on harmful emissions. Combined, the data sets pack a bigger punch. For instance, if MethaneSAT waves a red flag about an emissions spike in a given field, the California instrument would then zero in on specific facilities and pinpoint the larger sources. EDF says it is “like having two camera lenses — wide angle and telephoto” that together produce a more complete picture of the methane problem.
The California Air Resources Board and Planet Labs will work in partnership with the Environmental Defense Fund amongst others to set up a new Climate Data Partnership, a common platform for reporting data to enable governments, businesses, landowners and others to pursue more targeted mitigation measures worldwide.
Tom Ingersoll, who is leading EDF’s MethaneSAT project, suggests thinking of these separate but complementary data projects “as a set of overlapping circles, like the Olympic rings”.
He says: “Multiple methods of assessing methane emissions lead to a more complete and actionable set of insights than any single method can by itself.”
Bringing solutions into focus
Combining data captured via satellite imagery and artificial intelligence to monitor forests and land use to provide the ‘where, why, when and who’ was among the solutions discussed at a 4IR event held at the recent Global Climate Action Summit in San Francisco.
Kavita Prakash-Mani, practice leader – markets & food at WWF, says data from projects such as Eyes on the Forest, which investigates deforestation and land grabs in Indonesia, needs to be combined with other information to create the full picture. “We need technology to monitor why we are losing forests, looking at traceability through citizen sites and data on where food is coming from,” she says.
One example of this is the Trase platform, which connects independent data sources to reveal the trade flows for commodities such as beef, soy and palm oil which are responsible for an estimated two thirds of tropical deforestation. The aim is bring transparency to global supply chains, using publicly available data to map in detail the links between consumer countries via trading companies to the places of production.
The Trase platform reveals trade flows for commodities such as beef, soy and palm oil. (Image: Trase)
Using existing data such as customs records and trade contracts, tax registration data, production data and shipping data, Trase pieces together a bigger picture of how exports are linked to agricultural conditions (including specific environmental and social risks) in the places where they are produced. This enables companies, governments and others to better understand the risks and identify opportunities for more sustainable production.
By 2021, Trase aims to map the trade of over 70% of commodities that pose a major risk to forests. Clément Suavat, lead developer at Trase, says combining different data sets “allows you to connect landscapes, to quickly identify sustainability risks”. So, a mash-up of supply chain information and shipping data for example can help a business to pinpoint exactly where to make changes that will have an impact on climate change goals.
Sharpening the picture
Like Orbital Insight, which is using geospatial analytics to support the Global Forest Watch monitoring initiative, the Trase and Planet Labs projects are just some examples of this fast-growing field of using technology for climate change transparency.
Most recently, US climate change think tank Woods Hole Research Center is using a satellite-based tool to create a new global carbon monitoring map. The dataset behind the launch of The Carbon Source comes from the Woods Hole Carbon Monitoring System, which employs an innovative time-series approach to measuring changes (losses and gains) in aboveground carbon density across tropical America, Africa and Asia.
Woods Hole claims the approach is “poised to transform how the world measures and tracks changes in forest carbon” and its vision is to use the data “to tell a near real-time story” about the state and vulnerability of land-based carbon from the Arctic to the Tropics.
Dominic Waughray, head of the World Economic Forum’s Centre for Global Public Goods, predicts a “huge transformation” of the environmental community: “Think about how difficult it’s been to tackle climate change, to track emissions. And then think about the possibilities of large-scale transparency of data, and what that would mean to be a company or a civil society organization, finding that information and doing something with it.”
America’s governors, mayors and CEOs are forging ahead with climate change initiatives despite the Trump administration’s withdrawal from the Paris Agreement and commitment to reviving the coal industry. But a report published today sets out a roadmap that could quicken that pace and cut carbon emissions to 24% below 2005 levels by 2025 in the absence of federal leadership.
Many US states, cities and businesses have rallied around the Paris commitments since Donald Trump pulled out from the agreement in June 2017. The America’s Pledge on Climate initiative was set up the same year by former New York City mayor Michael Bloomberg and California governor Jerry Brown to map “bottom up” US climate action.
The US is already almost halfway to meeting its 2025 Paris Agreement emissions goal of 26-28% below 2005 levels by 2025. The report claims existing commitments and policies will drive US emissions to 17% below 2005 levels by 2025 – around two-thirds of the original Paris goal.
It also sets out 10 climate action strategies – across most major economic sectors including electricity, transportation and buildings – that, if implemented broadly, could lower emissions to 21% . Broader engagement and collaboration could bring this figure to 24%, the report suggests.
Strategies include setting and implementing more stringent renewable energy procurement policies, accelerating the phase out of super-polluting refrigerant gases, and mapping and repairing methane leaks from natural gas pipelines.
Researchers at the University of Maryland and the Rocky Mountain Institute, an independent thinktank, surveyed all 50 states, the largest 285 cities (100,000 plus population) and a cross section of businesses to map climate actions nationwide. Those committed to the Paris Agreement represent over half the US population (173 million people), over half the US economy ($11.4tn) and over 35% of nationwide greenhouse gas emissions.
Report co-author Paul Bodnar, managing director at the Rocky Mountain Institute, told The Guardian: “There have been growing coalitions in the US – cities working together, states working together, businesses working together. What’s changed in the last year and what’s new is this cross-cutting perspective. When states pass laws that help cities’ [emissions] strategies, or when states’ renewable portfolio standards are designed to help businesses – that’s really where we’re seeing really interesting, high impact results.”
The report, launched on the eve of Governor Brown’s Global Climate Action Summit in San Francisco this week, showcases examples of states, cities and businesses pioneering climate change initiatives.
Arkansas is the only state in the south-east with energy efficiency resource standards (EERS), which require electric and natural gas utilities to propose and administer energy efficiency programs. Since 2009, strategies ranging from customer outreach to new technology have supported these programs, resulting in megawatt-hour savings enough to power 28,000 homes for a year.
Los Angeles mayor Eric Garcetti was the driving force behind BlueLA, the city’s first all-electric car share program designed to sere low-income residents. Stations are located in LA’s most disadvantaged neighborhoods and is expected to take 1,000 vehicles off the road by 2020. BlueLA also employs community members to lead on education and outreach.
New Jersey’s largest utility, Public Service Electric & Gas used methane leak data collected by EDF and Google Street View vehicles equipped with leak detection sensors, leading to a 83% reduction in leakages.
Brown signed a bill this week pledging that the state will obtain 100% of its power from clean sources by 2045. California is the second US state to do so, following Hawaii’s pledge in 2015.
The report comes in the same week that the US Environmental Protection Agency (EPA) released proposals to ease monitoring of methane gas leaks. These would unpick the raft of rules introduced under the Obama administration in 2016 to monitor methane leaks because of their negative contribution to climate change.
Mary Nichols, chair of the California Air Resources Board and vice-chair of America’s Pledge, acknowledged that the bottom up approach “has no sanctions or penalties” but that it represented “a coalition of entities that have the capacity to make a difference”.
When she was diagnosed with breast cancer, Fauzia Aboud (middle) moved closer to home for the support of her family (Credit: David Macharia)
Cancer is the third highest cause of morbidity in Kenya.
Breast cancer is the second most common type of cancer in the country, with women under 50 accounting for 50% of those presenting.
Of the estimated 5,000 people diagnosed with breast cancer each year, around 2,000 will die from this disease.
Many of these women are mothers or carers, employees or small business owners so the impact is felt on their families, the wider community and on Kenya’s economy.
Navigating the cancer journey
Fauzia Aboud had recently given birth to her fourth child and was breastfeeding when she noticed that something wasn’t quite right. At first the 42-year-old, who was living in Tanzania at the time, dismissed what she’d found as a cracked nipple. Nothing to worry about, her sister reassured her. But when the discomfort persisted, Fauzia’s sister knew it was time to seek advice. One doctor’s appointment led to another and finally to a specialist who recommended a scan and biopsy tests that confirmed her breast cancer.
Living away from the support network of her family in Kenya, and with three children and a young baby to care for, Fauzia admits that the diagnosis in May 2016 and subsequent mastectomy surgery was “overwhelming.” So when her doctor in Dar es Salaam recommended returning to Kenya for follow-up treatment, Fauzia knew that she needed to move home and let her family help her navigate the next stages of this confusing and difficult journey.
How would she pay for the cycles of chemotherapy and radiotherapy that she needed? Who could she turn to for support on managing the side effects? And how would she be able to make the eight hour bus trip from Mombasa to Nairobi every few weeks to receive her treatment?
Listening to Fauzia and her sisters talk about these concerns brings into sharp focus the myriad challenges that people with cancer in Kenya face every day—from recognising symptoms and getting an early diagnosis, to accessing appropriate treatment.
David Makumi, chairman of the Kenyan Network of Cancer Organisations (KENCO). (Credit: David Macharia)
David Makumi is chairman of the Kenyan Network of Cancer Organisations (KENCO), the national umbrella body for cancer support groups and patient groups. He reels off some of the many complexities along the patient journey. For instance, a woman may discover a lump but lack awareness of cancer symptoms and not feel pain so will do nothing. If she does follow up, her doctor might not suspect cancer because of a gap in professional knowledge. If referred for a biopsy, she might not have the money to pay for it because her children’s school fees are due. And, when she eventually has the biopsy, the results may get lost so she has to start the process again.
“Then, if the patient finds out it’s cancer, the feeling is that cancer equals death because they don’t have enough information,” explains Makumi. “If there’s a district or county surgeon, they may do a mastectomy. The patient is booked to go in four weeks—she has to go back home, figure out costs, break the news to the family.”
After surgery, the patient may be referred for chemo and show up for two cycles then stop because she can’t afford to continue and doesn’t know how to access funding. Makumi explains: “These are primarily social issues, not medical issues; that’s where we come in. Information is an important piece that impacts on the way patients complete their treatment.”
The escalating burden of cancer
It’s 9am on Wednesday morning and the cancer centre at Kenyatta National Hospital (KNH) in Nairobi is already crowded. There are no empty spaces on the benches outside the chemo treatment room and its rows of hoods and chairs. Women and children stand where the seats don’t exist. Some people will have traveled hundreds of kilometers for treatment but may not even get seen today.
Upstairs in the cancer clinic, lines of men and women snake along the corridors, around corners and up the staircase as patients check in for open-door appointments at the public hospital, the largest referral facility in east and central Africa.
Non-communicable diseases (NCDs) such as cancer are a growing burden in Kenya, accounting for 31% of deaths in in 2015 and more than half of in-patient admissions.
The prevalence in Kenya of communicable diseases such as HIV, malaria and TB has led to the government channeling health spending towards these areas, with successful public health campaigns and outcomes. However NCDs have not been similarly prioritised until fairly recently, resulting in a cancer treatment and care infrastructure that struggles to meet the needs of Kenyans who develop cancer.
According to Robert Makori, assistant chief nurse at KNH’s cancer treatment center, the scenes at the hospital are the new normal. Makori sees 15 new patients a day so around 60 per week. An average 60-70 people are seen on the centre’s chemo days (Monday, Wednesday and Friday) between clinic hours of 8am to 4:30pm. From Monday to Friday, around 120-130 patients come in every day for radiotherapy.
Staff and clinic hours struggle to cope with patient volume, admits Makori: “KNH is the only public hospital with both radiotherapy and chemotherapy, and many of our patients have to travel a long way for treatment,” he explains. “A person could be given an appointment but if they’re not feeling well, they can’t have their treatment and may not get seen that day.”
Plotting the road map for cancer control
To address this escalating burden, the Kenyan government last year published the 2017-2022 National Cancer Control Strategy (NCCS) which builds on the work of the government’s first cancer strategy launched in 2011. It aligns with the Kenya National Strategy for the Prevention and Control of Non-Communicable Diseases 2015-2020 and with the government’s Kenya Vision 2030 commitment to improve the quality of life of all Kenyans.
More broadly, the NCCS is a response to the Sustainable Development Goal (SDG) target for 2030 of reducing premature mortality from non-communicable diseases, such as cancer, by one third.
Designed as a road map to how Kenya addresses cancer control, the NCCS has five focus areas: prevention, early detection and screening; diagnosis, registration and surveillance; treatment, palliative care and survivorship; coordination, partnership and financing for cancer control; and monitoring, evaluation and research. The strategy recognises that public-private partnership and collaboration with the non-health sector is pivotal to this work.
Financial access to cancer treatment is one of the biggest barriers to successful outcomes. Kenya does not yet have universal health coverage (UHC) although affordable healthcare for all is one of the government’s ‘Big Four’ economic development priorities.
Most Kenyans live on just a few US dollars a day, based on figures from the government’s latest economic survey. With an estimated 75% of the population not covered by a public, private or community health insurance scheme, paying for basic healthcare is already a challenge and paying for treatment for a life-threatening disease is even more of a stretch. According to the World Bank, nearly one million Kenyans fall below the poverty line because of health care related expenditures.
The state-run National Hospital Insurance Fund (NHIF) offers insurance to anyone over 18, with monthly payments based on income and starting from 150 KS (USD 1.50). Coverage was recently extended to provide 25,000 KS (USD 250) per patient towards cancer care.
But with treatment more likely to run into millions of Kenyan shillings and private finance interest rates of 20%-30%, many people with cancer have to rely on the Kenyan concept of ‘harambee’–community-self-help—or crowd funding to cover their costs. Alternatively, they go without treatment.
Makori at KNH comments: “Most people we see don’t have coverage so they start treatment but then 40% don’t finish because of lack of finance. It’s a challenge for our patients.”
A partnership approach to improving access
Rose Wambui was just 32 years old when she was diagnosed with breast cancer. The mother of two underwent a full mastectomy followed by eight cycles of chemo then 25 of radiotherapy. “It was quite a shock to get cancer at my age,” explains Rose, who had two children aged under eight when she was receiving her treatment.
When Rose’s oncologist suggested she pursue hormone therapy for her HER2-positive cancer, there was more worry: “It was so expensive and I knew that I couldn’t afford it.” It was then that her oncologist referred her to a special programme that KNH had set up to offer women free HER2-positive treatment. “I was overjoyed. I had to wait just one week then I started the treatment,” says Rose. “To have access to that treatment for free means a lot to us cancer patients.”
In Mombasa, Fauzia had begun her HER2-positive treatment privately but had to stop when her NHIF funding ran out. Family and friends pitched in to help her continue treatment and she even had to take out loans, but all fell short of her treatment costs. Finally, Fauzia’s sister Warda heard about the KNH programme and encouraged Fauzia to participate.
“I had been doing research and I kept thinking, ‘How can I lose my sister because of the cost of a drug?’ We thought it was the end of the road but then we heard about the programme and our imaginations started running wild,” says Warda. Through the KNH programme, Fauzia was able to complete the remainder of her treatment.
Fauzia and Rose are among the 82 women to date who have been able to participate in this programme at KNH thanks to an innovative public-private partnership formed in 2016 between Kenya’s Ministry of Health and Roche Kenya. The partnership, launched by First Lady Margaret Kenyatta, is designed “to improve access to timely and precise diagnostic services and tailored cancer treatment to make cancer therapy much more effective”.
Most Kenyans live on just a few US dollars a day, and paying for treatment for a life-threatening disease is a huge stretch. Special programmes like the one from KNH offer a solution. (Credit: David Macharia)
As part of this partnership, Roche and the Kenyan government have a memorandum of understanding to jointly cover the costs of HER2-positive treatment at public institutions (designed to be a stop gap measure until further NHIF or other government funding is possible).
Andre Mendoza, country manager of Roche Kenya and East Africa says that the partners had to take a step back and develop a holistic approach to improving breast cancer treatment and care in Kenya. “Public-private partnership was part of the government of Kenya’s strategy but the infrastructure was not ready,” he says. “The puzzle in front of us was how can we solve affordability issues—and everything else—through partnership so in the end patients can have access.”
Improving treatment through early diagnosis
An estimated 80% of cancer cases in Kenya are diagnosed at late stages due to low awareness of symptoms, inadequate screening and poorly structured referral facilities.
Dr Andrew Gachii, head of laboratory medicine at KNH, says: “As institutions, we’ve been grappling with infectious diseases and now all of a sudden we have this huge cancer burden. The unfortunate thing is that many patients come in late—stage 3 or 4—so some are just coming in for palliative care.”
To help improve early diagnosis of cancer, and as part of the overall partnership programme, Roche funded the installation of an immunohistochemistry analyzer at KNH. The machine is capable of advanced testing for seven types of cancer. Roche is also funding reagents for breast cancer testing at the 2,200-person facility.
The diagnostic equipment enables KNH to test whether a patient’s tumour is hormone responsive or non hormone responsive, indicating suitability for standard of care treatment for HER2-positive breast cancer. This is standard of care testing, now available for the first time in a public facility in Kenya. It is enabling patients to have a faster and much more accurate diagnosis.
With national screening guidelines still some way off, Dr Gachii says the partnership is helping KNH to improve diagnostics by providing more precise results but without the 10,000 KS (USD 100) fee charged by private facilities offering screening. He adds the cost of testing has been reduced to around 6,000 KS (USD 60): “Before we had the machine, less than 20%—perhaps two or three out of 10 patients—could afford tests. So 80% couldn’t get proper diagnosis to continue treatment.” Building capacity for cancer treatment
The Beth Mugo Cancer Foundation (BMCF) was set up in 2016 to promote access to information, detection and treatment of breast, cervical and prostate cancer. The organisation was founded by politician Beth Mugo, who in 1997 became the first woman to be elected to the Kenyan Parliament. In 2011, Mugo was diagnosed with breast cancer. Her initial response was to keep her disease a secret because of the stigma associated with it; eventually she began to discuss her cancer openly, attracting media attention and encouraging women across Kenya to get check-ups.
As part of Roche’s commitment to improving access to healthcare in Kenya, the company signed a memorandum of understanding with the BMCF in October 2016. Aimed at supporting people with breast, cervical and prostate cancer in Kenya, the agreement involves Roche providing training for BMCF employees on the subject of cancer and helping the foundation establish international links with similar organisations.
Building healthcare professional (HCPs) capacity is another priority. Kenya has a population of 45 million people, yet it only has nine medical oncologists across its four cancer treatment facilities. Makori at KNH comments: “We still have inadequate personnel… it’s not enough to manage the entire population.”
If the right structures, equipment and doctors could be deployed to every county, we could address the [cancer care] problems squarely.
Under the partnership with the Kenyan government, Roche is funding training scholarships for five medical oncologists and six oncology nurses, almost doubling the capacity of HCPs for cancer in the country. The training also includes support for two two-week surgical preceptorship programmes in biopsy techniques. The Ministry of Health has agreed to support and retain HCPs from scholarships and expand oncology treatment by increasing number of treatment centers and units.
Dr Angela Waweru, clinical oncologist at The Nairobi Hospital. (Credit: David Macharia)
Dr Angela Waweru is a clinical oncologist at The Nairobi Hospital (TNH), a private hospital, but is also on a six-month specialist attachment at KNH’s cancer clinic. Before joining TNH, Dr Waweru was employed by the United Kingdom’s publicly-funded National Health Service. She believes there is scope for further partnership between public and private cancer care facilities in Kenya to strengthen capacity. “I think that there’s opportunity for more. We do NHIF applications for patients at KNH and we’ve been treating the brachytherapy patients because the machine at KNH is out of action. Patients are waiting months for what we could do tomorrow.
TNH houses the Cancer Treatment Center, which offers a comprehensive service from diagnosis and surgery to treatment and rehabilitation. The center’s radiation treatment unit opened in 2012 and includes radiation therapy machines and a high dose brachytherapy unit. In addition to offering pro bono support to KNH with radiation treatments, lead radiotherapist Fredrick Asige says the center also offers free chemotherapy treatment to KNH patients with leukemia on alternate Saturdays as part of the hospital’s CSR programme.
TNH has also partnered with the NGO, Partners in Health (PIH) to offer free treatment to cancer patients in Rwanda. Under the agreement made in 2016 and supported by the Rwanda High Commission in Nairobi, PIH is funding the discounted TNH treatment over two years. Around 100-150 people are expected to be received radiotherapy treatments at TNH.
According to Mendoza at Roche, this approach to strengthening infrastructure began by listening to stakeholders to identify and fully understand the access hurdles to cancer treatment. “When we first started, the patient journey to get any sort of treatment was around nine months. The patient might get to another stage of cancer over this time and it might be too late. But with all these interventions, it’s now four months and going down. It is an ecosystem approach; you have to address all of the elements, or the patient will never get to the point of treatment.”
Jackie Wambua, stakeholder relations and health policy manager, Roche Kenya. (Credit: David Macharia)
Having champions like the First Lady and Senator Beth Mugo were key to opening doors and keeping momentum going, says Jackie Wambua, stakeholder relations and health policy manager, Roche Kenya. Wambua reached out to a range of stakeholders over two and a half years from 2015 before the government agreed to partner with Roche on breast cancer treatment. From early morning meetings at the Ministry of Health to listening to patient group concerns via KENCO, she joined the dots to help make the programme a reality.
“We had committees with government, Roche and KNH on what protocols do we need, what guidelines do we follow,” she explains. “We had to look at processes that weren’t there and set up ways for the patient to navigate from casualty or from referrals outside city.”
Against a background of devolution of health services in Kenya, with counties being given a bigger responsibility in prioritising and allocating resources, Kenya’s cancer strategy provides a framework for planning and implementing cancer prevention and control interventions.
Makumi at KENCO advocates for screening to be done at county level via outreach clinics once or twice a month. Makori at KNH would like to see the government offer the private sector incentives to invest in healthcare and provide equipment so that people with cancer can have the same treatment without having to travel across the country.
Removing the stigma of cancer
Although breast cancer occurs in both men and women, more than 90% of cases present in women. Risk factors include gender (being female), family history, alcohol and tobacco use, being obese or overweight and exposure to estrogen hormones through contraceptives.
Makumi at KENCO also believes faith-based groups have a role to play as partners in spreading this message. “We looked at what worked with HIV and what changed the tide is when religious leaders got involved in talking about HIV in temples, in mosques, in churches, in the shrines, in the places of worship. When they started doing that then folks listened. So we want to craft specific cancer messages especially around prevention.”
Dr Tom Menge, chief pharmacist and deputy director, pharmaceutical services at KNH, agrees that cancer needs to be a public health priority. “Look at how the country dealt with HIV/AIDS—it was a concerted effort, declared a disaster and addressed issues of access,” he explains. “I believe that’s the direction that cancer is going.” He adds that the National Cancer Institute, currently in a formative stage, will contribute to this vision. “We worked on an amazing model for HIV; I keep wondering whether we can do same for cancer.”
Diya Melanoi Mohamed, another patient on the Roche/KNH treatment programme, wants to see more information about cancer treatment options. The 58-year-old and her husband, Farooq, had the support of their grown-up children to navigate her treatment. Farooq, who had recently retired when Diya was diagnosed with breast cancer, researched options and kept careful notes about his wife’s surgery, chemo and radiotherapy appointments.
But Diya knows not every patient will be as fortunate: “A lot needs to be done around education. Whether rural or in town, when you hear cancer, you think it’s a death sentence, it’s scary. But when you meet friends and talk freely about cancer, they’re surprised and realize you don’t have to be scared of it.”
The Kenya agreement is part of Roche’s Africa Strategy which began in 2015 and is working with local partners on a range of initiatives including strengthening healthcare systems, professional training and private health insurance with local companies. Markus Gemeund, head of Roche in sub-Saharan Africa, says the next step in Kenya is to find creative funding solutions. “The biggest challenge is funding and reimbursement. Cancer is cancer—it doesn’t wait for the economy to do well.” To this end, Roche is looking at what other creative funding mechanisms can be put in place until countries like Kenya have universal health care.
Back in Mombasa, Fauzia talks about reopening a hairdressing and beauty salon like the one she worked at before her cancer treatment. What would she wish for others who are newly diagnosed with cancer? “No-one should be afraid to reach out,” she says. “You will get help if you’re willing to look for help.”