Education, Equity & Women’s Health in Kenya with Dr. Marleen Temmerman

Podcast Introduction and Guest Background 0:00

Welcome to the Doctors Making a Difference podcast, where we help physicians to be empowered with the tools they need to successful in medicine, in finance, and in life. Join us as we highlight doctors and other professionals around the world who are making a difference. I'd like to welcome Dr. Marlene Temmerman. Dr Temerman is here with us today. I think you're gonna find this very interesting. She has worked in Kenya for years. Like she grew up and went to medical school in Belgium and has had a fascinating career across a variety of places.

And I've been following her work for several months. It's been trying to make the time zones connect so that we could do this recording. and I'm delighted to be able to do the recording today, so Dr, Temerman, would you mind introducing yourself to our audience? Sure, Peter, thank you and thanks for inviting me today. So my name is Marlene Tamerman. I'm a Belgian national obstetrician gynecologist, also trained in public health and global health. And I live and work in Kenya, in Nairobi and in other places where I am a professor of gynaecology at the Aga Khan University in Nairoubi.

Yeah, that's me. Well, it's awesome. I want to go back to when you started this. You mentioned before we hit record that you always wanted to work. Um, you mentioned either in Africa or South America, developing countries to make this, this change. And so do you mind telling us about that? How did you end up doing that, because you start it off as a young person, a lot of people have aspirations and dreams of, of going and making this large impact, but you've done it, throughout your career, which is quite interesting.

So walk us through that journey a little bit. Thank you. So as a young girl already, I wanted to, it was equity. I want to make sure that people around the world had the same chances. And so I was always very engaged and I went to do medicine to be able to work globally in Africa or in Latin America. To make a difference, maybe very naive when, you know, we are young teenager, but It was a dream that really kept me going. So I did medicine, which was already unusual because girls from my social class and my generation, you know, they did not go to medical college,

Early Career and Path to Global Health 2:25

but I managed to convince my parents. We worked hard. And so I didn't medicine and graduated in 78 from Ghent University and wanted to do gynecology. But when I knocked on Professor's door to ask for a residency please, then he said, but you know, what are you asking? Gynecology, well, you are a woman. And he looked at me like, oh, yes. So then- Which is crazy from today's standards. It seems like most OB-GYNs are women. But at that time, they gave you this crazy feedback, that you're a women, how could you want to do this?

Yeah. Interesting. Yeah, because who will take care of your husband, your children, You know, why don't you do dermatology or something else that you can organize your life? So the doors were closed. I became a GP, but the dream was there and that was before internet, so I had to write letters to universities in my own country, in the Netherlands, and Germany, France, Europe, everywhere in UK. Finally, I found the position to start my training in The Netherlands. and could continue later in Brussels, in my own country, to become a gynecologist in 1983. Meanwhile, I had followed a master's in public health and tropical medicine because I wanted to work globally.

And my opportunity came and I remained in academia because I wanted to work, you know, academia you can do research, can teach, and you do a lot of service delivery which is clinical work. So I was at Brussels University and then the chance came. in the 80s, mid-80s because I had already visited University of Nairobi where there was a small group doing research on gonorrhea, chlamydia, sexually transmitted diseases. And then the new virus came, HIV. So I was invited to move to Nairo for two years to lead research with, the question was, Can HIV have an impact on pregnancy outcome on children?

We didn't know anything about it. It was really the pioneer's work. And I joined a small group at University of Nairobi with Canadians. Later University Washington joined and it was a really great. I worked in maternity in rather the slums in vulnerable groups in Nairobi where We had 80 to 100 deliveries a day, every day. That was really the cradle of mankind. A lot of people came, and it was purely a maternity, maternal and newborn health. Doing research, we set up the research site for HIV, of course a gold mine, for research.

In 87, 3% of the women were HIV positive. A few years later, 30, three zero. But besides doing research, we saw women dying of preventable causes. So many needs. I started working as a clinician, raising funding, setting up, going to embassies, to UN agencies, through fundings to really invest in the maternity. I imported the first ultrasound machine in Kenya in 87. I was pregnant myself then, very motivated. Oh wow, yeah, you were motivated! Oh yeah absolutely. But it really changed the way of doing medicine.

So I stayed finally six years, together with my husband, my baby, the boy. Then after six year we decided to go back to Belgium. But I was so grounded in Kenya, I had started an NGO there, the International Center for Reproductive Health, to work with Kenya colleagues, with the communities, and the ministry to improve women's health and rights. That NGO is still there. It started in 1994, then in Kenya in 2000, also in Mozambique. So we have a kind of a network of NGOs working on international center reproductive health, sexual and reproductive rights.

Meanwhile, I did my PhD on HIV and pregnancy.

Nairobi Research, Maternal Health, and NGO Work 7:10

Of course, we did a lot of research on that topic. Defended my Ph.D. and became, later in Belgium, the first professor gynecology and the Benelux female professor, sorry, first woman. And in my own university, where at that time they were happy to have a woman there because patients were asking for women gynaecologists and all staff was only men. So I was, initially the door was closed, but so many years later, I was welcomed and worked at the university in Ghent. And I asked my vice chancellor, can I start a center here for support and research capacity building globally?

A multidisciplinary center, not only medics or nurses, but also social scientists, nurses. Human rights, because it's a lot about women's rights that we are doing. So I initiated all this and came to Kenya very regularly. Then the next step in my career, I was asked to run because at that time in Belgium, it was a kind of an influence. I wrote books, published of course in the scientific literature, became a professor at the university in Ghent and was very often on radio television about women's issues.

Leading to, I was invited to run for elections, 2000, early 2000. Initially I said no, no I don't have time. In Belgium. So I say no way, too I'm too busy in the clinics and I am doing research and leading these NGOs, so on, but finally I says yes. I became an elected senator in my own country, working in university in parliament, which I don't regret because I learned a lot. When you are leaving your comfort zone and you do a lotta work for women's health and rights, you publish, your write books, and assume that the world knows about it and that it will have impact.

It has impact to a certain extent, but you know, parliamentarians, they don' t read the Lancet and they shouldn't. We should do better to talk to the parliamentarians, to the parliaments, the governments, through the communities, though the media, we should develop this working with constituencies and highlighting the points that are so important. For me, throughout my career, maternal mortality is one of the biggest inequities in the world. Why are women today still dying, giving life? So many here in Africa.

In my country, it's never zero. But like in Belgium, we have like five to six women dying for every 100,000 deliveries. In Kenya, its 350. So there are so many inequalities and it is a very strong indicator of inequality. We work around this, but also about around adolescent health and rights, family planning, early marriage, the whole women's rights agenda. So I spent two terms in politics and at the end of that second term, I was invited to go to join WHO, The World Health Organization, where I became the chair of the director of The Department on Reproductive Health and Research, Women's Health.

And so I stayed in WHO. Learned a lot again. because working with the UN, not only WHO, but also UNICEF, UNFPA, you form UN Women, really a global community where we could move these agendas on women's health and women rights. So then, meanwhile, all the time I went back and forth to Kenya, to the NGO, the university, Pumani maternity, where I lost my heart so many years ago, to try to upgrade the services. So then, now 10 years, when I retired from WHO, I, of course, my husband, myself, our second home, and now even our first home is Kenya.

I relocated to Kenya again in 2015, the Aga Khan University where I'm still working, doing the same action. What is that? Working in the university but also in communities, in vulnerable poor communities in a country to try to improve the health systems, not only at the University but working with the Ministry of Health. For example, I have been appointed now by the governor here in Mombasa a big county as the chair of the board of largest hospital here in Mombasa. It's a 730 bed hospital where we are trying now to invest in improving maternal health, reducing mother's death, children's, but also going into the non-communicable diseases.

There are a lot of women here who are dying of treatable diseases, cervical cancer, Breast cancer is a big issue. So together with WHO, with partners with countries in the neighborhood, we tried to get really this work up and going. And I must say we have also, like many of us actually, really been impacted by the US government policies reducing US aid. Many of our projects were funded by US Aid, so we had to lay off some of our staff, we had to close some our programs. And we see the impact on maternal health.

We see again, Kenya had done very well in controlling HIV AIDS. So we have a very low rate of babies born, neonatal HIV infection. Now it's going up again because the funding has gone down. The government is trying very hard But the thing is that these programs have been stopped abruptly. And we see the impact really in the field, you know, more in young girls.

Politics, WHO, and Returning to Kenya 14:00

The most vulnerable in society are the young girl. They have more new cases of HIV, they get pregnant, You know, the power to decide very often on their own lives. A lot has changed, I must say, because since many years now, all boys and girls have to go to school. The girls who go school, they do better, very oftentimes than the boys. But it's still a big, so many more girls here in Kenya and young women, They are strong, The Gen Z is very vocal. They're intelligent, they are taking leadership positions, but there is a big gap with the poverty that we see up country.

And we are trying with our communities, the Aga Khan community, uh, NGOs, ministries. We are really trying to make a difference, But it is big, big problem. It's not only the funding from US also from European countries. You know, there was really a pushback which we Truly regret. Yeah. Well, you know, it's interesting to hear this incredible story you've told. Most physicians, look at this and say, well, I want to become a good clinician or I think it would be fun to be involved in international work or occasionally people get involved You know, much less the World Health Organization, you've had a chance to kind of dip your toes into every one of those things and be heavily involved.

And even at this stage of your career, You're still very involved in what's happening in Kenya. I'm like you say, it's the loss of funding is abruptly is it has a huge impact whether no matter where the payer source I've been able to I been privileged to go to Africa on a number of occasions to do medical service work. And you can see a relatively small amount of money can go a very long way toward prevention programs and education and empowering people to solve their own problems. What have you noticed between when you first started this work in the 1980s until now, what have noticed about like the people in Kenya?

What've you notice about the attitudes and the understanding and educational regarding preventable disease? Kenya is a great country. I love Kenyan people, of course, otherwise I wouldn't be here. The population, so when I came here in 85 till now, population has doubled, more than doubled. There were like 22 Kenyans there. Now there are close to 60. So, family planning and population growth is still there, but we have seen major impact Surely in the urban settings where we have the more educated families and they go to like, they rather prefer to have three to four children, two to three, to give them a better education than the traditional large families of country, which is still a big gap.

So Kenya has evolved a lot, as I said earlier. The fact that education, boys and girls have to go to school. Education is the, for me, it's kind of the number one to change a country. You know, if you educate the people and surely the women of a county, you will see changes and Kenya is seeing these changes, absolutely. So more education more innovation technology. Some of things in Kenya are the numbers one. We pay with and pass. It's on our phones. All Kenyans, they transfer money everywhere. So that means that the coverage of a phone, a smartphone is very high.

That gives other opportunities. We have an advance. we do everything on a smart phone. Sending money, paying. There are some technologies and many more in Kenya. A lot of innovation technology and so on. The health sector has also evolved a lot. But still, we are struggling with the big difference between private sector and the public sector. Public sector is struggling. The government is trying to have a kind of social health authority that every Kenyan should be covered, but the vulnerable populations, many of them, they don't have IDs, so there is a big gap.

is, again, back to education. Here in Mombasa, for example, in the coast, there was no university till about, what, 14 years ago. Then the polytechnic changed into a university. And with a small group of people, we were so excited that we came to the university, to a brand new university we asked them, do you have a medical school? No. Do you want a med school, yes, of course. So I then contacted my vice chancellor at Ghent University, the dean. We brought these communities together. Then the government built a building on campus.

A little bit of funding here and there. And now next week, 4th of September, we open the first medical school here in the county. So this is a huge opportunity for the coast. Coast has always been neglected to also have their medical school. We have now only 40 positions. The government, the governor himself, he is also sponsoring a few more. So we will start with like maybe 50 students. we had 450 applications. so we built this curriculum, but we still need, and I'm doing fundraising all the time, We would really want, in my university in Ghent, we have a fund that is called Fund Marlene Temmerman, where Belgian people, they provide some money that we are using for Kenyans and Mozambicans and others to go for higher education.

I'm also, still now, I have about, maybe I've finalized 60 PhD students, most of them from here, who were given the opportunity to do research. Better now they are clinicians, people from the ministry, researchers, but we have a community that helps them to publish, to raise funding, raise grants, and then to invest in their own career. I see my old students now. Years ago, they are now vice chancellor of university. They are in the ministry. In Swahili, we call them the mama kupua, the big mamas, big papas.

The leaders. And that's really what makes me very happy. Contributing to development. and to make sure that the Kenyans, they have so much potential. They are the leaders of the future. It's not me who has to talk about problems of female genital mutilation in the country. Of course I can talk it. We do research, we know the problems, but it will only change with the young Kenyan women and men who come forward and who really want to stop this harmful practice. Same with child marriage, teenage pregnancy, so many problems.

But now with all these young people that we didn't have 40 years ago, there were hardly female students at the university and they were very much,

Kenyau2019s Progress, Education, and Medical School Launch 22:00

they hardly could speak to a professor. Now they are the ones coming in the streets. They have a vision, a mission. So a lot has changed and that's why I believe in this country and the countries around because With education, you can develop your middle class. There will always be a difference between the poor and the rich and so on, but important is that you give education job opportunities and that the middle-class can, develop themselves, can become the future leaders. So for me, it's very important.

And everyone who wants to help there, You are very welcome. Well, like you said, education is the key. I think you made a good point. If you show up as a person from another country and tell them all their problems and what to do, very few people will actually change. But if you educate people and help people to become empowered so they understand it themselves, then you're now seeing the fruits of your labors. Decades later, you see All these intelligent people who have been educated, they understand the problems from all sides, both culturally and scientifically.

And then they go back to their communities and say, okay, let's make change from within. Well, that'll leave a multi-generational impact and it'll let people pull themselves out of that poverty cycle. I like your comments about developing a middle-class. We've noticed when my group's gone to Uganda and Kenya before, there's just not much of a Middle-Class, at least out in the rural areas. And so if you can develop that, you get a group of people that's educated, they have the same goals as everybody.

They want a peaceful life with low disease and the ability to take care of their families. And that that wonderful. It's really pretty neat that not only do you have these wonderful ideas, but you've been able to actually do it. Now you're living in Kenya, seeing the fruits of your labor, and you are starting a medical school. Pretty cool. Nice. Next week we are so excited. Yeah, absolutely, because that will make a big difference. The hospital where I'm working now here in Mombasa, the Coast General Teaching and Referral Hospital, it's a government hospital with a lot of problems, but also a love of steps.

You know, we have developed a beautiful cat lab, a new ICU, or pediatric accident and emergency. We are now raising funding locally and internationally too. really become not only for Mombasa, but for the whole coastal area, which is about five to six million people, to have cancer detection, screening, treatment. Because like the women who are coming here with breast cancer, very often they are too late. Cervix cancer. We have in Kenya every year about 6,000 women die of cervix cancers. another 6 to 7,000 or breast cancer.

So many the same numbers of birth giving life. With better systems and technology, we are also in the university of course participating in new technologies, looking at AI, artificial intelligence in medical diagnostics. But it's good to develop that, but it can only have an impact when you can really use it in the population, not only for the upper class, the very few who have the money. So that's what we are trying to work towards. And I'm sure that we can make a difference even in this coastal area.

We need support, we need really So, and there are Kenyan philanthropies. There are rich people, of course, in Kenya. And some of them, they really also invest in their community. They pay back to their communities. I've recently met a group of people because all these years that we worked in this maternity, Pumani Maternity Hospital calculate If you have like, now it's a bit less. It's 50 deliveries a day, but still a lot. The millions of Kenyans who are born in that facility, many of them are now big leaders, businessmen making a lotta money, politicians, you know, rich people.

So we are setting up kind of a fund, saying a group, we call them the Children of Pumani. And calling upon them, you have seen, You have to pay back to the place where you've seen the light, right? Where you are born and you're a healthy baby grown up. So I mean that motivates people to invest in this facility. That's the kind of work we are doing. Advocacy. but also working with NGOs, with the communities, because it's the community, not me. I'm still, you know, Kenyans in so many years. And I feel like a Kenyan citizen, but I am not a Kenya.

So I think it is the Kenans. Although my books, my first book I wrote in my language is called Mamadaktari, and that's also my Twitter name. Mamadaktari is Madame Doctor in Swahili. So, but I think it's, you know, I feel like it is the Kenyans now who are taking over. It's not, we can only support. We can give them the opportunities to indeed take care of higher education, to do their PhDs or to, Because our students from Belgium, they come here, the medical students, from Ghent University. They come her already like 30 years and longer for their electives.

That's fine. But Kenyan students need, there needs to be reciprocity. Kenyans students needs go to Belgium. Maybe not to work in our maternity because they learn much more here. By to learn technology, to become maybe, you know, in radiology and engineering. So that's what we are setting up this reciprocity between the different. Another question on this is, so funding sources are hard. You mentioned the sudden cutting off of USAID, which is a big one. How do you see outside of trying to get people in the country, especially those who have been successful in business or other things, how do see fundraising going forward?

Because it's a deal. Most countries that are sub-Saharan Africa, the average income for people is very low. Sometimes it is one or two dollars a day for a laborer and so it very low income. And at this point, Kenya and all of sub-Saharan Africa really does depend on outside support and money for a lot of the development of these programs. So how can people get involved? How would you see funding going forward for some of those programs? Yeah. As I said, we suffered from the US aid stop, also NIH.

We had a number of NIH programs in universities. that are coming to an end. So we have, of course, we work with other European programs. Horizon is a good funding agency, but cannot really fill the gaps. I'm not talking about research. There are, also, the European partners, from government support. It's going down for many countries. We are happy that there are big foundations, so we live part of us. surviving our programs with the Bill and Melinda Gates Foundation. The Gates foundation is supporting our community programs, but also a lot of innovation and technology and trying to, they really have a huge, huge impact here in Africa.

So we are very grateful for that. And we have many, many programs. But the ones that I know is the women health program. where they work in maternal health, child health. Immunization, family planning. Now also more and more into sort of maternal help, but also in other health problems.

Funding Challenges and Health Program Impacts 30:40

Survival cancer is one of them. So we work, we get a lot of support from them, which is good. There are a few other foundations we are really reaching out and trying, but you know, like for most of my work in academia is supported by grants. Grant writing, it's really major undertaking. If you write five grants with your team, or 10, and you have two that are awarded, you can be happy. We have to train the people in writing, grants, publishing, so it's a continuous challenge. Like this year, by the end of next year my team at the University of the Aga Khan University, my research team is called the Center of Excellence for Women and Child Health here in Nairobi at Agha Khan university.

We were like 80 people, all of them, making all us from the highest to the lowest based paid by grants. So without the global reduction on support, we are now 45, so we had to lay off quite a number of people. The NGO, the International Centre for Productive Health, is the same. We tried to, and then we said, well, you know, not to depend too much on donor funding, maybe the system. But the fact that it happened so suddenly, I could accept that the donor, like you as a saying, look guys, you are now evolving and you have to take gradually more and more of your own business.

We reduce maybe international collaboration or funding with like 10%. It was hard to go from 100 to zero, 100-0 all at once, very hard. It's impossible. And then you lose all these people who have been trained, the capacity. In the hospital, we had a very good comprehensive care clinic for HIV patients. But we have to lay off these patients, and there is less women who are coming now for the PMTCT as prevention of maternal transmission of HIV. that is going down again because the money is not there anymore or only a bit to test the moms to provide them with antiretroviral medication.

So it has an enormous impact, yeah. Well, HIV specifically is a disease that it's a worldwide disease. So what happens in Kenya or any country, if you have a large disease burden go up, you know, that does tend to impact people worldwide. I think it is money well spent when all countries look toward prevention programs that help people to not have that. And so that is big problem. You know, another question for you is, so a lot of people listening to this podcast, most people listen to these are physicians.

And there's somebody out there listening saying, boy, Dr. Timmerman has had this amazing career. How do I get involved in something like that? What would you tell an aspiring young physician or someone who's been in practice for a while and says, hey, I want to give back to the world community and I wants to be involved. how would tell them to begin the process of trying to become involved? There are so many opportunities. I think wherever you are in the world, whatever you do, let's say now young physicians, what can you?

You become a physician. The first thing is that it's important that you deliver good medical care. Whatever specialty or GP or whatever, you treat your patients with high quality. You follow the guidelines. you make sure that have a good respect for the patients you're dealing with. So that is kind of the basic, but how can you be involved in every community? There are opportunities to get engaged in community health centers, to do some work for free, voluntary work here and there. If you are at the university, you can be in research, in global research.

There we have a number of U.S. partners, like we work with the university, we worked with Johns Hopkins University, We work at the University of Washington in Seattle. We worked at Michigan University just to name a few. So with these universities we exchange programs. we had young doctors, U S doctors who work we teamed them up with kind of doctors or healthcare workers from this part of the world, there are a lot of opportunities for scholarships and to get engaged. The best projects are the ones where you have a sandwich program with a US person, with somebody from here, and you grow together, you develop these capacities together.

But even if you are not in universities and wherever you're in the World, if there is an opportunity and if you are fully busy with your own business, you don't have time to engage, maybe you can share some of your wealth like the foundations are doing. We mentioned the Gates Foundation, but there are others as well, of course, who can who share part of their fortune and then maybe invest in this kind of global health or global society programs. There are many. Well, I think everybody hopes for a coming day like what you envisioned when you started out.

Some of these inequalities, some of the things where a nice person is born in Europe and a Nice person was born and sub-Saharan Africa and yet the opportunities for health and education and things are just so vastly different. And so what I hope for today When those equalities are improved and a lot of people have different outcomes, but if we can provide some more parity in the opportunities people haven't and I think I heard a comment once about, you know, some of the artificial intelligence technologies may be really beneficial in some lower resource locations because if you don't we, I know just at home when.

When you have an EKG or a radiology read, sometimes there's automatically a, you know, a preliminary interpretation that comes out on some of that stuff.

Advice for Physicians and Closing Remarks 37:10

That could be a big, big benefit. If you say, well, we have a ultrasound or we. X-ray and we don't have radiologist look at it yet, but we a really clear idea of what this is and some ability to share screens across continents to say I need someone to look this. I think that provides a lot of awareness and. And from a medical standpoint, that helps. And so there's ways for people to get involved, whether through a local foundation or a university, or send your dollars to work in places like where Dr.

Temmerman works. Yeah, like telemedicine is already starting to grow here. you know, that people don't have to come, but you can do with telemedicine, you could do a lot. If I may, just one advice to the young people maybe who are listening, I think in my career I come from a very humble family where girls usually don' t go to university. My three brothers was no problem but I had really to convince my daddy who was saying, but you know, why don't you become a teacher or a nurse? Why do you want to go to universities?

That is not for our kind of people. But they allowed me, and I would say if you have a chance, take it, number one. My mother always said, if you want to reach for the moon, maybe you grab a star. It's of course the opposite, but I mean, so grab the opportunities. Then the other thing I would say, don't take no for an answer. I've been told so many times in my life, this is not possible. This is, you can't do this. this not for you. Not for us. Is not. Possible. You can become a gynecologist. Okay.

Become a medical doctor. Just saying no. Meet me even more. convinced I will do it. So don't take no for an answer. And then another one is also maybe don' be afraid to leave your comfort zone. Because if you go somewhere else and you talk to other people, it felt like a bit, oh my God, what is this? I don''t understand what I'm doing here. Will I be the right person to say something? Me in parliament? Oh my god, no, so you always think, Why can I not do the same as somebody else or even better?

Surely for girls, it's really a step, you know, an extra. They have to make, to prove that they can do those things. So the girls who are listening to the young women, be sure that you can as well as your boys, colleagues, the men, even sometimes because you have fight even harder. Wonderful advice. I appreciate it. How can people follow your work? Like I've been fascinated by what you do. I was introduced to you by one of our previous guests, Megan Missanelli. She had an episode that came out on the podcast on May 23rd.

If you want to listen to Megan's wonderful podcast, but she was just fascinated, by Dr. Temmerman's work. And I appreciate her introduction. How could other people, follow you work, what's the best way for them to see all the things that you're involved in? So my LinkedIn account, just my name and you find LinkedIn. We have websites from the International Century Productive World. Aga Khan University, I must say, they need to be a bit updated, but LinkedIn is probably the best. I still have Mamadaktari is my Twitter account, and I don't do much more there.

Yeah, that's the most You can always write me an email, of course, you can share my email address. Yeah, if you don't mind, I'll share your email and the show notes, because again, what you're doing is very important. You've already observed that it's leaving a major lasting impact that will persist for decades and decades, and hopefully generations. And I think that those little seeds that you've planted in the 1980s are still bearing fruit, will bear even more fruit in the future. And so we're preaching this to the next Dr.

Marlene Temerman. There's more people out there who want to be involved in like in this type of work. I appreciate you taking the time to share your story. i find it inspirational and I think it's amazing what you're doing, what have done and what are you still doing. So thank you for what your doing! Thank you Peter for inviting me. Thanks for tuning into the Doctors Making a Difference podcast. And thank you for what you do to help your patients and your community. Your work truly helps so many people.

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