A doctoral student, his mother and the practical uses of public health science
Chris Bernard Otieno Agala knows what he wants to do.
For Agala, science isn’t merely a tool to uncover facts. Science is what might have saved his childhood. His mother was 38 when she died of breast cancer. When she died, he was 14. “That’s when my family collapsed,” he said, as his gaze seemed to focus on that loss back in Kanyipola, Kenya, a few kilometers from the shores of Lake Victoria.
Agala, 37, is now a doctoral candidate in health policy and management at the Gillings School of Global Public Health and a fellow with MEASURE Evaluation in the Carolina Population Center. The little agricultural village where he grew up may seem like an unlikely place for a career in public health to begin, but Agala’s childhood there inspired his work.
As a boy, Agala wove papyrus mats with his father and grew vegetables with his mother in the family plot. Once or twice a week he walked with his mother to the market village of Aherro in Kisumu County to sell them.
Their family had 10 children. Two girls died in infancy. One surviving girl died young of tuberculosis. He was the second boy among seven, eventually the eldest after his older brother died young of HIV/AIDS.
His mother was the glue for the family. “My mother was the strength, bedrock, motivation and source of our security and inspiration,” he said. “She cared a lot about our well-being and achievement in school. She was there for us even when she was sick and unable to walk.” When she died, the family lost the bulk of its livelihood.
“We didn’t have enough money for my mother to travel to Nairobi for treatment. Our ill family members were never on treatment,” he said.
After his mother’s death, Agala – whose friends call him “Bernie” – focused on school, a decision his family supported. He received a scholarship to the Starehe Boys Center and School in Nairobi, the start of his transforming trajectory. He went on to attend Starehe Technical Training College, studying computer science, and then entered Kenyatta University, where he majored in finance. “I was the first in my whole village to go to college,” he said.
In addition to school, Agala had a three-month internship with a local nongovernmental organization (NGO) working on public health information technology issues. Three months as an intern became almost a year as a paid worker, helping public health researchers analyze data. He was put in charge of interviewing children and their caregivers. “My role kept expanding. I ended up in the field with these people and that’s how I met the Duke folks.”
After he graduated from the university, he was hired to monitor the HIV/AIDS projects sponsored by The Global Fund. The Duke researchers he met through his previous internship invited him to enroll in a training course in Amsterdam. He got his first passport in less than a week and soon found himself on his first airplane ride then in his first snowball fight. After his training, Duke assigned him as lead interviewer working with a Duke research project implemented by ACE Africa, a Kenyan NGO.
MEASURE Evaluation provided some of the tools and training used in the project. “We depended a lot on MEASURE,” he said. “And I on my mentors at Duke.” Duke asked Agala to come to Durham for two months of further training in community resource management, research ethics, research methods, institutional review board and management of research staff. Duke then hired him to oversee three studies in Tanzania. After four years, his Duke mentors suggested he apply for the doctoral program at UNC. And that’s how he came to be in Chapel Hill and at MEASURE Evaluation.
Agala’s work today focuses on how to provide improved access to health treatment in an environment of scarce resources. Science has identified treatments for HIV that extend life expectancy and quality of life, he said, but who receives the treatment is often determined by resources.
Anti-retroviral therapy is made available to those whose viral load meets a specific threshold. If their count isn’t high enough, they don’t get treatment and may continue to infect their partners. “The existence of that threshold is based on scarce resources,” he says. “How do we wisely use our resources? I don’t know how WHO [the World Health Organization] and governments will answer that question, but I’m sure that one day everyone will get treatment.”
His dissertation examines referral networks in Ethiopia and their ability to get people to start HIV treatment and stay on it. MEASURE Evaluation provided the data set. Jim Thomas, MEASURE Evaluation project director, is one of five people on Agala’s dissertation committee.
Agala is looking at patient attitudes and satisfaction with care. He will factor in how distance affects their retention in care and how their attitudes toward the network of caregivers affect their adherence to treatment. As for the networks themselves, he will be asking questions about staffing and budgets for optimal performance of provider organizations and how to improve the quality of care and avoid delays in treatment. His results will show what motivates the network and the providers within it, how good networks for treatment perform and how they can be sustained.
His work will influence health policy, but it’s also personal for Agala. If a family can’t secure treatment for a member who is ill, he said, “it increases the disease burden for the family. It leads to loss of livelihood. It leads to not seeking appropriate care because it costs resources for the family.” Like what happened to his mother, his family.
“Back home, we have low resources and much need,” Agala said. His manner is quiet, his voice soft – even more so when he remembers his mother and wonders if treatment might have saved her. His research is too late to help his mother, but Agala sees it as an investment for the future in her honor.
Agala hopes his dissertation and public health research will result in more people receiving potentially life-saving treatment for as long as they need it. “For any disease, but cancer is a big problem,” he said. “I am looking at science in its practical sense – to impact people’s lives…immediately.”