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“We need scientists who are in Africa focusing on African problems,” says Edwine Barasa of the Kenya Medical Research Institute–Wellcome Trust.

KATTY HUERTAS

A Kenyan health economist investigates the pandemic’s puzzling course in his country

Sciences COVID-19 reporting is supported by the Pulitzer Center and the Heising-Simons Foundation.

In 2007, Kenyan health economist Edwine Barasa had a long layover at Heath­row Airport. A fervent supporter of the London-based soccer club Arsenal, he saw a chance to fulfill a lifelong dream: visiting the club’s ancestral stadium in Highbury. Even though he didn’t have the right paperwork, he managed to con­vince an immigration officer to stamp his passport—with a warning that he abso­lutely had to be back in 12 hours or they would both be in trouble.

The incident speaks to Barasa’s te­nacity and powers of persuasion, says his boss, Philip Bejon, who directs the Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme. These traits, Bejon says, have served Barasa well in his role as director of the program’s office in Nai­robi, where he’s been a key player in Kenya’s response to the COVID-19 pan­demic. “Edwine always shows up as an authentic and sincere scientist who convinces his colleagues.”

Over the course of the pandemic, Barasa has worked with epidemiologists to reveal the surprisingly small impact of the disease in Kenya—so far. He has advised the country’s Ministry of Health on how to allocate its lim­ited resources. And he’s been a part of the team guiding KEMRI–Wellcome Trust—a long-standing collaboration between Kenya and the United King­dom—as it assists the government with testing and viral sequencing, and hosts a Kenyan trial of the COVID-19 vaccine produced by the University of Oxford and AstraZeneca. Barasa believes his field of health economics has much to offer the pandemic response, which entails making life-or-death investment deci­sions quickly, with limited information.

Until recently, posts like Barasa’s—directing internationally funded research partnerships in Africa—were typically held by white Euro­peans. But Barasa belongs to a generation of young African research leaders now stepping forward. On social media, he has challenged the prevailing powers in the field of “global health”—and the long tradition of researchers from rich northern countries studying poor countries’ health problems. He doesn’t view himself as a natural leader, though. “I don’t find it comes easy,” he says.

Barasa trained as a pharmacist in Kenya before moving to South Africa to do his master’s degree and Ph.D. in health eco­nomics at the University of Cape Town. Susan Cleary, his postgraduate supervisor and present-day collaborator, describes him as a “superb academic as well as a fine hu­man being—humble, kind, and courageous.” Along the way, he published five papers while also getting married and becoming a father. He wanted to finish his Ph.D. before his son was born, but despite completing his degree in a record two-and-a-half years, he didn’t quite make that deadline. “I was late by 3 months,” he quips.

Back in Kenya, Barasa took leadership of the KEMRI–Wellcome Trust health economic research unit in late 2015. Two years later he was promoted to his current post. He is closely involved in Kenya’s efforts to make its health system accessible and affordable for its 53 million citizens, but the pandemic put those reforms on hold.

As coronavirus patients flooded hospitals in Europe early in 2020, Barasa grew increas­ingly anxious. “I just wondered, if these coun­tries are struggling, what will happen when this pandemic hits the African continent?” In a preprint published on medRxiv in April 2020, Barasa and two colleagues estimated, based on early epidemic modeling, that the demand for intensive care beds in Kenya could outstrip supply by a factor of four.

Luckily, those predictions turned out to be wrong. On 15 April, when some models had predicted Kenya would hit 1000 reported cases, the official tally was just over 200. One month later, when models had predicted more than 10,000 cases, the country had reported only 758. Al­though official numbers likely under­counted asymptomatic infections, fears that hospitals would be overwhelmed did not come to pass. After Barasa and colleagues modified an existing sur­veillance system for tracking illness in children to record trends in all-age ad­missions for severe respiratory symp­toms, they found that the number of COVID-19 patients in intensive care in the entire country never exceeded 60 during Kenya’s first peak of infections. Even Kenya’s limited health system could handle such numbers, he says.

Another clue that the disease was often milder in Kenya came when Barasa and colleagues tested more than 3000 Kenyan blood donors for SARS-CoV-2 antibodies, a sign of previous infection. That work, pub­lished in Science in November, sug­gested more than 7% of Nairobi’s 4.4 million inhabitants had been ex­posed to the virus by May. Based on modeling, the researchers concluded infections had peaked in the capital in July with 30% to 50% of the population infected. Yet hospitals were not overwhelmed.

Why the pandemic has played out so dif­ferently in Kenya and some other African countries isn’t clear. Young people are less susceptible to severe disease, and Kenya’s median age of 20 (compared with 47 in Italy) is “pretty much the only factor where there is clear evidence,” Barasa says. Other possible factors, such as climate, genetics, or immu­nity due to previous exposure to other patho­gens, haven’t yet been fully investigated.

Bejon notes that Barasa has a special knack for engaging policymakers in the de­sign of research studies, which “has resulted in research becoming more closely attuned to what is needed nationally.” Barasa has a close working relationship with the Ministry of Health, says Kadondi Kasera, a scientist based at the ministry’s Public Health Emer­gency Operation Center. “We have worked with Edwine and his team to generate a num­ber of policy and evidence briefs that have informed the ministry top management in designing preparedness and response mea­sures,” Kasera says. The work has included calculating the cost of treating a COVID-19 patient in a Kenyan hospital and providing advice on reopening schools.

Barasa has also helped the government target its limited resources. At the start of the pandemic, many feared Kenya didn’t have enough ventilators to keep severely ill patients alive. “That became the narrative,” he recalls. But over time, it became clear to him that instead of spending thousands of dollars on ventilators, which only a few Kenyans would need, it would be wiser to in­vest in pulse oximeters. These devices mea­sure blood oxygen levels and can be used to determine which COVID-19 patients need supplemental oxygen—insights that benefit many more patients than ventilators.

Kenya’s first pandemic wave proved not to be the tsunami Barasa and others feared. But after peaking in July and August, new cases rose again. Between 12 October and 8 November, the number increased by an average of 34% per week, to just under 1500 cases a day. Since then, both new cases and deaths have been tracking down. Ris­ing immunity may have helped curb both Kenya’s waves, Barasa says, though he won’t say communities are nearing herd immu­nity. “We don’t know how long immunity lasts,” he adds.

Some Nairobi hospitals may have become overcrowded in October—probably because people from outside the capital were seeking care at the country’s best facilities, Barasa says. Yet with only 22% of Kenya’s popula­tion living within a 2-hour walk of a health care facility with intensive care capabilities, the surge in rural cases could bring fresh con­cerns. And protecting health workers is also proving tricky: Dozens of doctors and nurses have died in the new surge in cases.

Still, with African labs and research cen­ters providing more evidence, governments are now better prepared to face those chal­lenges, Barasa says. “One of the things the pandemic has shown me is that we need local capacity, and we need scientists who are in Africa focusing on African problems.”