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Thomas Kenyon (Dr.), Country Director for Center for Disease Control and Prevention (CDC) and the Department of Health and Human Services (HHS) in Ethiopia from 2008 onwards, has been appointed as the Director for Center for Global Health at CDC in Atlanta.
Capital’s  Aderajew Asfaw sat down with him to discuss the contributions he made and challenges he has faced in Ethiopia and elsewhere in Africa.

Capital: You have been working here for more than four years. How was your stay?
Thomas Kenyon:
It has really been a fulfilling and rich experience with a lot of progress being made in the health sector though there is still a long way to go. We have been mostly working on HIV/AIDS, which has come down dramatically. New infections are way down; mortality has also declined considerably. There’s still some ways to go, but we are pleased to be a partner in the government’s programs to address health issues and in the significant progress that have been made. As you know, we are supported by the Presidential Emergency Plan For AIDS Relief (PEPFAR). Ethiopia has been an important country for PEPFAR, but we still have to do more and I think that would be the main lesson as even though a lot of success has been made, we should not let up because if you do that with HIV/AIDS, it will come back with a vengeance and will spread through different populations if people on treatment don’t strictly adhere to the treatment. Other countries are learning the hard way that, when they are relaxed, HIV/AIDS incidences came back up. For instance, Uganda is one such case. Ethiopia is changing rapidly and becoming urbanized. The rural and urban areas are becoming more interconnected with new roads, new construction projects.  So as social networks change, that could affect the way HIV/AIDS is spread. So the government needs to keep doing what it is doing, but also make sure that they are on top of issue like where the epidemics is and where it is going.
Capital: What do you think, as the leader of the CDC, were the challenges for the center in the past four years?
Kenyon:
First of all, there are a lot of problems in addition to HIVAIDS. But in the case of HIV/AIDS how you prioritize to become the best partner with the government and trying to understand that, as new information becomes available and as new science come to the fore, how do you translate that into action are major challenges. Our tendency is to get projects going, and then along comes new information or new science. It is difficult to change and adapt projects using the new information quickly. But you know that is just one of the realities of this epidemic and others and that we have to adjust and adapt fast. But as I said, it isn’t always easy and I found that challenging.
Capital: Currently, there aren’t medical treatments in the US for malaria as states have been able to eradicate the disease from the region. What do you think Sub Saharan countries in general, and Ethiopia in particular, should do to reach that level?
Kenyon: It is interesting that you raised that, because that is how CDC got started back in the 1940s. Our military was trying to train soldiers in the South of the US to prepare them in case of combat in hot and moist climates. The biggest problem they had was that the soldiers got sick with malaria. It took a very concerted effort to eradicate it – to rid the reservoirs of mosquitoes by preventing them from breeding by spraying and other methods. There are examples even more recent of course of countries who have successfully achieved this. But that’s how CDC got started as an agency and that’s why we are based in Atlanta.
It is going to take perseverance and I think people are doing the right thing. But it is not an easy battle, because you are dealing with mosquitoes, with parasites, with poverty that may put people in high rate settings, with no choice but to be a farm worker in an area where there’s malaria, and government budgets are stretched to be able to do all the required spraying or all the testing that needs to be done and all the treatment that is needed. Capital: The government has always been criticized when it comes to realizing recommendations based on best practices from international organizations, especially on issues of business and politics. How do you think its commitment is in customizing recommendations on health issues?
Kenyon:
By and large, they do accept recommendations. I think they follow World Health Organization (WHO) guidelines.  At CDC, it is part of the process to develop WHO guidelines on the global level, taking evidence-based approaches. Budgetary realities that might make it very difficult to do something when leaders might want to. For example, we want to make treatment more accessible to patients who have earlier contracted HIV/AIDS. Right now, we are waiting until people are pretty sick or have pretty severe immunity suppression, before we start treatment. Most countries are now trying to make it available earlier, before it has reached that stage, but that has cost implications. I think in such a big country as Ethiopia, cost implications could be quite substantial. So, most of the time, if there is reluctance, it is not because of not wanting to do the right thing. It rather is because there would be budgetary implications. The HIV/AIDS response requires substantial external input from PEPFAR and Global Fund. We hope that, as the economic situation here improves and as the government invests more and more into social services for its people, that HIV/AIDS would be included in those discussions, because ultimately, the government has to sustain the response. We have been doing this for a decade now. PEPFAR was announced by President Bush in 2003 and it really picked up in 2004. We are in the 10th year of doing this. Therefore, it would be very important for policy makers, politicians, and decision makers to invest more in combating the HIV/AIDS epidemic and also malaria to the extent that they can.
Capital: Why do you think the issue of HIV/AIDS isn’t as hot as it was a decade or so ago?
Kenyon:
We don’t have the mortality like we used to. In fact, the mortality rate is down by 70 percent. I can tell you what a nightmare it was before treatment started, which was in 1990s in other African countries. The corpses were piling up in burial grounds and funeral homes, left and right, at all times of the day, at all times of the week. It really was a nightmare. Now with treatment, you don’t see this. So, people are starting to forget what a catastrophe HIV/AIDS wreaked. We mustn’t forget that and I think what transpired in the 1990s and in parts of the last decade should not be forgotten. If we do, then we would relax when it comes to HIV/AIDS and that would be a disaster.
There are economic issues that affect HIV/AIDS. It is not that it is a disease emanating from poverty. It is a disease of economics. We know mobile populations have a higher risk of exposure. That’s an example where economic decisions affect a person’s life. So, these issues are all intertwined. There are many determinants of HIV/AIDS, but social networks and others that affect sexual networks will also affect how the disease is transmitted. Therefore, economics is an A factor and not a B factor, to consider. 
Capital: Your bio indicates that you have worked in other African countries too. What differences have you noticed when working in Ethiopia?
Kenyon:
I have worked in three African countries – Swaziland, Botswana and Namibia – at different times of the epidemic. In Swaziland, it was a beginning and I was a pediatrician, so we saw many children die. In Botswana, we did more research before treatment, but we still saw many deaths from TB than from HIV/AIDS. We started treatment programs which started the reversal of mortality. Each country has been different. If you ask me about the working conditions, first of all, the work ethics here is very high. I am so impressed by how hard people work. The work ethics is really commendable.  I have been inspired by the Ethiopians I have worked with. That has been the best part of my experience, seeing the commitment of health workers, which inspires partners to want to help. I remember a health officer, a young woman in her early 20s in Kombolcha, who was providing all the HIV/AIDS treatment as there wasn’t a doctor at the Kombolcha Health Center. I saw so many patients and she had to work on Saturdays and Sundays too. I asked her why she was doing this and her response was: “Well, these are my people; what choice do I have?” She was giving her time way beyond what the government was asking of her to serve her community. I think that is a very unique characteristic and that Ethiopians will maintain that commitment. What also is different here is that it is considered an honor and privilege to be a health worker. That is not the case in every country. I think that is a very positive attribute that the country has.
I am sure that there are economic challenges that health workers face in terms of salary, benefits and all of that and we wish the government the best in solving those issues. What we can help do is provide them with the necessary training and make them sound health workers, but also help create a conducive environment in which they can work.
Capital: There is an acute lack of physicians here in the country, while there are many doctors in the US, Europe and other corners of the globe. What do you think should be done to retain these people?
Kenyon:
Well, again, I think there are economic realities that must be faced and historically, Ethiopia has trained very fine doctors who have been marketable internationally. A lot have left long ago for personal reasons. Many are doing things to give back to Ethiopia in various ways, for example, some by coming back to work on specific projects. Some of them have returned and brought their families back with them. But the government’s approach, which PEPFAR supports, is to train more people as well. Even with the current output, they are not going to address the need that they have. I believe there have been massive efforts to establish new medical colleges. There are 17 new medical colleges I know about. The challenge is going to be in ensuring quality, but I think they have the faculty to, not only teach them what’s in the books, but also what’s in a patient [how to handle a patient].
I think that’s the current trend of the medical education system, which has a very high student-to-faculty ratio. So how can they mobilize perhaps doctors in the private sector, doctors from outside, how can they make better use of information technology to educate more doctors? But their approach, as I understand it, is to very much increase output. But focus must also be on quality too.
Capital: Can you tell me when you first became aware of and came into contact with HIV/AIDS cases?
Kenyon:
Actually, when I went to medical school, HIV/AIDS hadn’t been described and when I graduated, it was first reported. When I first came to Africa as a medical student, we didn’t see HIV/AIDS cases, but when I came back five years later, it was a slaughter. So, the HIV/AIDS epidemic was happening silently at the time. My first encounter with clinical HIV/AIDS was in Africa and it was the most frustrating thing I have been through. We saw a lot of mortality. You see a child and you know the mother is infected. But you didn’t have the treatment for them and you didn’t have time for them, because the whole world was full of children.  I saw many health workers leave the profession because they said: “We just can’t do this anymore.” There were doctors who said they were not going to take care of patients because they knew they were going to die.  That was the case in the 90s. So I sometimes wish that I had an encounter with the disease when the treatment was available for the first time. It was really difficult.
Capital: Having been here in Africa for quite a long time, are you going to totally say goodbye or are you planning to continue contributing in resolving the continent’s health issues in a different way?
Kenyon:
Well, everyone at the divisions with the Center for Global Health has an engagement with Africa. Therefore, I am not saying goodbye to Africa. In fact, if you look at the burden that disease has caused worldwide, about a quarter of it [roughly speaking] is within Africa. In some cases even much more than that. For instance, 2/3rd of the epidemic of HIV/AIDS is in Africa. So you can’t work at Global Health without being engaged in Africa. But I think that Africa also has a lot to share with others. If you look at the way we test for HIV/AIDS in America, a lot of those approaches came from Africa, because we learned in those hot epidemic situations how best to test people. Now, the US has adopted some of those same policies and procedures. So, we can learn from each other  and we can learn from Ethiopia as well.