Category Archives: Public Health

Globalist or Statist, Ebola is a Health Systems Issue

As the world holds its breath on how the latest Ebola outbreak in West Africa might evolve, a clash of statist and globalist approaches has been evident all through; from media analysts, to International NGO’s to governments. Statist approaches have their reference point as the state/country and tend to view health risks as security concerns while globalist approaches have the individual as the reference point and tend to consider health risks as human rights issues that know no borders.

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A map of West Africa detailing the most affected areas by the EVD.

In classical statist responses, the government of Zambia has banned entry from or travel to any of the four most affected countries; Nigeria, Liberia, Sierra Leone and Guinea. Neighboring Ghana and Ivory Coast have suspended flights within the region while Guinea, itself the epicenter of the outbreak, has closed borders with her neighbors Sierra Leone and Liberia and even declared a state of emergency! The latter three countries have deployed troops at their borders to help enforce movement restrictions. Similarly, many Americans, in the wake of Dr Kent Brantly’s airlifting, voiced reservations at their government’s decision to import the virus onto US soil. In fact, retired famous Neurosurgeon Dr Ben Carson is on record recommending that the two infected Americans should have been at best treated abroad. Back home, many Kenyans are apprehensive and concerned that the virus might make its way into the country aboard the national carrier Kenya Airways, a major carrier connecting West African countries to Kenya. A suspected case late last week (Aug 9th) threw panic across the city. Thankfully, he tested negative. These measures are reminiscent of the early days of HIV/AIDS when fear and panic rather than sound medical principles informed most reactions.

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An electron micrograph of the Ebola virus

The common theme through statist approaches is the definition of disease as a security threat to the nation akin to an invasion. As a result, nations tend to go onto the defense and shut borders, ban flights, expel victims, declare states of emergency and at the bottom of the list, even deploy propaganda. Granted, the socio-economic disruption across West Africa as a result of this outbreak is indeed a threat to the stability of the most affected nations. While in certain instances some or all of these interventions might be helpful, they are seldom successful of their own. Purely statist approaches, beyond securitizing the health threat and evoking a pervasive sense of fear, often overlook the actual necessary interventions.

“The bottom line with Ebola is we know how to stop it: traditional public health,” US CDC Director, Dr Tom Frieden.

In the case of Ebola, a viral infectious hemorrhagic fever of which there is fair medical knowledge, proper hygiene and isolation of symptomatic victims seem to help forestall further spread even as a cure remains elusive. At best, only about a third of infected patients may be nursed back to health. That said, Ebola outbreaks remain either an indictment or appraisal of a health system’s infection prevention and control mechanisms, sensu lato.  This outbreak has therefore merely put to the fore an underlying and long prevalent rot: health systems that are weak from the foundation up.

In as many Sub-Saharan hospitals as homes, clean running water remains a luxury rather than the basic commodity it ought to be. Further, basic and cheap protective gear like gloves and facemasks are frequently out of supply. It is no guess whether these institutions would have enough of costly supplies like intravenous fluids and colloids for the medical support of potential Ebola survivors or management of other conditions. The last nail on the coffin that such a health system represents is surprisingly not the prevalent biting shortage of qualified personnel nor the mismanagement of the few available skilled hands, it’s the population!

“Ignorance and poverty, as well as entrenched religious and cultural practices, continue to exacerbate the spread of the disease,” President Ellen Sirleaf, Liberia.

Many Africans are yet to adopt the germ theory of infectious disease. Developed in the mid 1800’s, this theory remains the most plausible explanation for infections: that tiny living matter (bacteria, viruses, fungi, etc) must physically enter a susceptible host through a particular mode (air, food, blood, etc) in sufficient numbers to cause a disease. With this knowledge, people are forewarned and therefore forearmed on ways to avoid known infections. For Ebola, this means limiting if not avoiding all unprotected contact with infected individuals and bodies of victims and washing up adequately when such contact occurs. Sadly, many individuals still believe diseases like Ebola are curses that need exorcism or just prayers. The sick and bodies of the dead are handled casually every day; Ebola or other disease.

As more of Africa opens up to itself and the world, future outbreaks might be more complex and widespread in the absence of significant systemic changes on the public health platform. However, this threat also presents hope. The growth that is opening up and connecting Africa might come with more medical workers in the unreached areas, greater economic strength for adequate stocking of facilities with essential supplies and greater population knowledge and practise of basic hygiene and sanitation. Additionally, improved communication networks mean future outbreaks maybe detected earlier and aid to stricken populations availed sooner.

Globalist approaches to public health crises know no borders. They view health risks anywhere as a health risk everywhere in cognition of the inherent value of human life, right to a dignified pain-free existence and the interconnectedness of humans. These approaches therefore focus on open borders for collaborations, funds, skills and supplies to affected areas, advocacy for action and open reporting of events. An Africa seeking greater ties within itself and with the rest of the world will have to adopt more globalist approaches to our numerous public health perils.

“African states must do more to promote conditions for a dignified human existence within their borders.”

Finally, even though investment in proper health systems is one sure way to healthy populations, these efforts must not stop at the hospital level. The bulk of health dividends will be reaped from investment in other sectors. It is ignominious that 50 years post-independence, many African countries have yet to supply their people with adequate clean water, clean energy, safe public transport, adequate food and enough relevant knowledge. Globalists and other non-state actors will continue to play  a role in this respect but the long end of the buck lies in the hands of our respective states to do that they were set up to do: promote conditions for a dignified human existence within their borders.

Learn about Ebola

The Kenya Medical Practitioners and Dentists Board, What is It?

The Kenya Medical Practitioners and Dentists Board is a statutory body established by Chapter 253 of the Laws of Kenya in 1978. As the name suggests, the primary role of the Board is the determination, licensure and maintenance of an annual register of duly qualified doctors and dentists.

To achieve this, the Board regulates and supervises the general practice of medicine and dentistry, conduct of internship and the academic programs of medical school programs. Contrary to public opinion, the Board is neither a welfare society for doctors nor a tribunal for medico-legal cases. In fact, the Board’s mandate in medico-legal disputes is only indirectly implied in the Act that establishes it! However, its operations and decisions might make it appear as either: depending on one’s perspective.

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By composition, the Board is a ‘special-interests’ body drawing appointees from government, medical schools and doctors. The Cabinet Secretary for Health appoints the Chairman and nominates at least four other doctors. Additionally, the Director of Medical Services and his deputy are automatic nominees to the Board. In fact, the DMS is the Board’s registrar. After government, the next most represented interest group are the medical schools; each sending nominees to the Board.  Finally, duly registered doctors have seven slots to the Board filled through an election. Tenure for all members is a renewable term of five years.

The bare minimum qualification for Board membership is a due registration as a doctor/dentist. In principle and letter of the law, a newly qualified Medical Officer is as eligible to the Board as is a Paediatric Neurosurgeon of 20 years. Traditionally though, members to the Board have been highly qualified and extensively experienced senior doctors. To its credit or disdain, the Board has been an unofficial holding ground for appointment to senior government positions or conversely, a halfway house from top echelons in government.

For more details, follow these links to Chapter 253 of the Laws of Kenya (the primary reference source for this article) and the Board.

Do These Lives Count for a Thing?

On the morning of September 11 2001, the United States of America woke up to what remains one of the most atrocious acts of terror on civilians. In a span of minutes, nearly 3000 people lay dead following the multiple airline hijackings and suicide crashing. That day is immortalized in history.

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Aftermath of 9/11 at the World Trade Centre

Even more enduring are the changes that occurred in the wake of the attacks. Not only has airline transportation practise changed worldwide, internal national US security, immigration, banking finance, foreign policy and military practise have all been affected in one way or another.

Two months after the attacks, the Transportation Security Administration (TSA) was established with the core mandate of securing US transport systems; focussing on air transport. This mandate was later emboldened through the establishment of an entirely new Department of Homeland Security one year later. Twelve years on, airline and passenger safety in the US is a near-impregnable multi-layer behemoth system that spans the globe. There has been no repeat of the ignominious events of 9/11.

In achieving this feat, new laws were crafted and zealously implemented. New institutions were established with the mandate and wherewithal to achieve their specified objectives. Investment in new technology, training of personnel and public education have all been components of an all-out commitment to prevent, pre-empt and manage the next 9/11.

The raison d’être for these sweeping changes would be the sanctity and value of human life. There is no greater wealth to any nation than the lives of her people. Indeed, people are to a nation what good health is to an individual. The loss of a single life anywhere invariably shatters many other lives. Children are orphaned, spouses are widowed, parents bereaved and friendships cut short. The direct loss of productivity of the deceased and their grieving social circle cannot be quantified. Attendant expenses in emergency response, treatment, rehabilitation and funerals only make the pain and cost of avoidable death unbearable.

In Kenya, we live through a 9/11 on our roads every year! I have never lost a close relation in a road accident but lost my own dad to a fatal stroke. The sudden emptiness that engulfed the entire household remains palpable one year on. Each time the now regular road crashes grab the headlines; I cannot help but feel the pain, agony and anguish the families of the victims bear. It baffles me how the authorities charged with road safety live with their conscience through crash after crash to an annual tally of well over 3000 Kenyans! Thomas Jefferson’s words that, “The purpose of government is to enable the people of a nation to live in safety and happiness” ring hollow in these circumstances.

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An accident scene in Kenya

Unlike in the US where the loss of 3000 lives marked a turning point of global significance, our departed kin die in vain year in, year out.  Are we just numb to the sheer pain of fellow citizens? Or are our own goals in life too grand for us to care about them? Alternatively, is it lost on us that this untamed beast will come calling on us or kin sooner rather than later? Still, are our lives of lesser value even before our own eyes?

We still grapple with (and lose invaluable lives in the process) the same old failures that make our roads unsafe. The number one determinant of all road fatalities remains speed yet the enforcement of the law on this single factor remains in limbo. Driver aptitude is roundly recognised as equally significant but we have not made even baby steps in reforming training, empowering and educating current drivers or even consistently punishing errant behaviour. Whenever we flex some muscle, it is usually an uncoordinated, limited and short-lived reflexive jolt in response to the latest tragedy. A common spectacle in those moments is the inspection of public service vehicles by the roadside. One wonders how such inspections appraise components like brakes, lights, wipers, emissions and so on. Pointedly, the focus is usually on licences, body paintwork, extra passengers, tyres and other such easily apparent failings. The irony is that in a spectacular misapplication of technology, drivers whose vehicles are found at fault are instantly fined, pay their fees on the spot and proceed in their death shells!

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An impromptu roadside vehicle inspection in Kenya

The ‘hero’ medal in today’s airline safety goes to the passenger (especially in the US). Even before one’s flight, one could already be on a ‘flight watch-list’.  Then there is the ever growing list of prohibited items to check. Even those items allowed must be in certain quantities and packaging. A one hundred per cent baggage inspection means baggage must bear special or no locks lest they be broken into for one’s own safety. At the airport, traditional terminal car parks are now replaced by drop-off zones. Armed and uniformed military personnel are at hand and cameras record entire termini. Then there is the full-body scan by x-ray machines and so-called pat downs by TSA officers. Meanwhile, shoes get a dedicated x-ray session as one tugs on barefoot. As if that were not enough, the person on the seat next to you could be a trained security officer planted there for your safety.

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A typical full-body airport x-ray scan image.

Such is the seriousness with which life is guarded. Many passengers do not exactly love the ritual that air travel has become in the wake of 9/11 but they neither do they loathe it. Instead, most see it as necessary inconvenience whose dividends are too valuable to wish away. This understanding has partly been achieved not only by complete and constant communication with passengers, but also by co-opting passengers as stakeholders in the safety/security war. Even more important, a legal framework ensures everyone in the process plays their bit professionally and efficiently.

Back on our Kenyan roads, while passengers generally understand the basic safety regulations like seat-belts, non-speeding and safe loading, there has not been a demonstration of a compelling commitment on their part to these requirements. Too often, passengers board full buses for the selfish (nay foolish) expediency of saving time. In hospital beds, passengers recount tales of speeding or otherwise reckless drivers whom they did nothing about.  Our losses on the roads have continued to be directly borne only by those immediately affected. As a result, a pervasive tolerance to this carnage has made sure the rest of us do not do our part in transportation vigilance until it is our turn to bear the loss.

The authorities need to empower passengers to report safety abuses by acting decisively on all reports. While the police have a particularly heavy legal responsibility to instill discipline on errant road users, we citizens bear the ultimate responsibility. If the police will not do their part, we should be selfish enough to demand better. Our safety is for the most part for our own individual good. It is now obvious not one of the numerous public officers whose job is to enforce road safety looses sleep over a road crash. At least you should give your safety a second thought and ultimately some action. It’s your life!

Michael Bane writes in his book Trail Safe: Averting Threatening Human Behavior in the Outdoors, “Risk is the increased consequence of failure.” We have made our roads risky by that which we fail to do. As a pedestrian, maintain your wits about you while by the roadside or crossing the road. As a passenger, ask the speeding driver to slow down and do it over until you feel safe. Other passengers may find you a nuisance but make no apologies for being safe. Wear your seat belt if provided. Do not board when there is no seat for you. Be selfish and jealously take guard of your life. Should you be the driver, common sense, traffic rules and courtesy should be your mantra behind the wheel. Even if you believe in an after-life, your family and loved ones cherish your presence more in this life. Should you fail to honor your duty to safety, like the over 3000 lives lost on the road in Kenya this year, your life will be lost in vain.

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An accident victim in a Kenyan hospital

Safe Driving Drives Safety

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An old surgical adage goes, ‘A good surgeon knows how to operate, a better one when to operate and the best one when not to operate.’  On the road, the best drivers know when to give way and when to stop. Put simply, knowledge comes hand in glove with responsibility and judgment. Of the 1.2 million annual road deaths worldwide, 70% occur in developing countries, which host only one third of the world’s vehicles.  It is an unsettling normal that, like a sad annual target, over 3,000 lives will have been lost by year-close in Kenya. In the process, another 15,000 are maimed to various extents. Majority are productive young citizens in their prime and the so-called vulnerable road users – pedestrians, cyclists and motorcyclists. Occasionally (which is frequent), a bus swallows 40 citizens in one gulp and triggers knee jerks all over for a while before ‘normalcy’ returns. These losses transcend just the deaths; families are left destitute, children orphaned, and many other lives turned topsy-turvy. The overall toll on the economy and society is far-reaching and ought to be a call for not just concern but systematic targeted action.

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In the coming years, the WHO predicts road fatalities to account for the third leading cause of death in developing countries by 2020. Growing populations and economies, urbanization, increasing vehicular traffic and inadequate infrastructure, systems and policies will all contribute to the carnage.  This knowledge, rather than be reason for despair and prayers to God for protection, needs to be a tool for preparation. Like anything else that works well, road safety is a system of deliberate actions by definite actors in concert to a common goal. Within this system, the fellow behind the wheel takes the lead when it comes to making a difference. Over 90% of all accidents on the road are a result of poor/lack of driver judgment and therein lays the problem in road safety. Punitive laws and fines may deter poor road ethics but laws unto themselves do not make a people. Rather than emphasize fines, bans and arrests, it is better to lay focus on policies that would make drivers more knowledgeable, courteous and skillful. Needless to add, drivers operate machinery on roads. These two other components (vehicle and road conditions) must also be addressed. For this discourse however, we focus on the driver as the primary determinant.

There are three critical ingredients of the safe driver: cognitive skills, social skills and physical ability. None is more valuable than the other is but the first determines how much of the rest a driver would muster and how well they would deploy all the skills. These skills develop from raw knowledge, past experience and a baseline cognitive ability. Driving schools only teach the basics of safe driving; the raw knowledge of law and common courtesy required on the road. However, the skill of safe driving is acquired by experience through the deliberate application of all the three ingredients mentioned above.

A driver’s cognitive skills inform their understanding of their ability, the condition and performance of their vehicle, the applicable road regulations and the prevailing road conditions. By merely getting a vehicle on to the road, the driver ought to be certain already of the vehicle’s service condition for its purpose and their ability to operate it safely. Whether the road is unfamiliar, unmarked, dark, narrow, potholed or otherwise, common sense dictates the driver must judge what speed is safe for their ability, vehicle and laws. Perhaps the most important cognitive skill in driving is the perception of an accurate temporal-spatial awareness and acting on it appropriately. Safe drivers are aware of what is around them at all times. They look out for other road users on the sides, from the rear and from afront in relation to their position and speed. They also keep an eye their own vehicle’s instrument panel for their current performance and aberrations from the normal. They constantly attempt to predict the actions of other roads users and prepare for them. Even though 90% of all driving stimuli are visual, hearing, smell and vibratory senses all contribute to the safe driver’s awareness. To do all these requires utmost concentration and alertness behind the wheel and a measure of intelligence.

Alcohol consumption before/during driving is outlawed primarily because it numbs all these senses and therefore impairs our judgment and reaction time. Physical fatigue and sleep deprivation have an almost similar effect. However, other numbing factors are less apparent. Benign activities like chatting with your passenger, changing the CD, tuning the radio, using your cell phone, adjusting the air-con and fixating on scenes outside can distract from the task of driving and lead to fatal consequences. Research shows that if drivers involved in accidents had an extra second to act, 80% of accidents would be averted. It is in the split second of inattention that accidents occur.

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The second ingredient in the bag of safe drivers is social skills. As a matter of courtesy and safety, drivers are taught to give way whenever it is safe to do so. In some instances, courtesy is actually a law unto itself. The green traffic light for instance does not symbolize a right to proceed at all costs, but rather an indication to proceed if safe to do so. The zebra crossing demands that one lowers their speed even when they do not spot any pedestrians while the stop sign/red light demands a stop even in the absence of other traffic. Courtesy means a driver should not tailgate, accelerate when being overtaken or misuse their lights or horn to intimidate other road users. Safe courteous drivers do not surprise other road users by their actions, they appropriately indicate their intentions to turn, stop or overtake. They pull over from the road when they anticipate a fault or need to stop and alert other road users of the same. They make sure they are visible on the road at all times: fog, rain, dust, dusk, dawn or night by using the right lights. They do not blind oncoming drivers neither do they hog the road to themselves on a two-way.

The last component, physical ability, is rather obvious. One must be able to physical reach the vehicles controls and manipulate them appropriately. A comfortable well-positioned seat, well-padded pedals, the gear lever, instrument panel and location and operation of other controls contribute to the safety of any driver. Further, proper eyesight, hearing, smell and touch are all valuable to operate a vehicle safely. Children are barred from driving partly because of their physical handicap. Equally, persons with disabilities must have specially kitted vehicles and may actually not operate certain heavy machinery that require more physical strain and dexterity. Nevertheless, reach and operation of the controls is only safe in normal driving circumstances. Emergencies and special situations demand a different type of physical ability and co-ordination. This has to be learnt separately and practiced over time. An intelligent driver would not bring formula antics or emergency-vehicle (ambulance, police, fire) maneuvers onto the public road in their stock vehicle.

With all the three ingredients in place, a safe driver – like a safe surgeon – knows when to proceed and when not to. He knows what skills to deploy for what conditions. Advances in technology have solved some of the issues. Modern cars have automatic headlights, daylights, turn signals, anti-collision systems, lane detectors and a retinue of other gizmos that enhance safety with little or no driver input. Like trains, driver-less cars are already on the roads and seem to cause significantly less accidents than their human driven counterparts do. As a primarily used-car market, most Kenyan vehicles are roughly 5-10 years behind current technology. Regardless, the responsibility still rests on the driver to appraise their skill, vehicle and road for accurate and appropriate decisions behind the wheel.

 Most drivers have the necessary physical ability and coordination for a safe trip but courtesy is sorely lacking. To a debatable extent, some drivers either do not exercise their cognitive skills or simply lack them. The work of any driver behind the wheel can be reduced to four functions: to constantly identify potential dangers, predict how they would occur, decide what to do if and when they occur and execute sensible mitigating measures.

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It took the developed countries about 40 years to lower their road fatalities from rates similar to Kenya’s today (60 deaths/10 000 vehicles) to an average of 2 deaths per 10 000 vehicles. We do not have that kind of time in our hands. Besides, the advances in technology and research and experiences in developed countries mean that what works is now well known. As for drivers, the responsibility for road safety lies squarely in our hands (and feet). I find it irreconcilable that barely literate persons can acquire driver’s licenses and be expected to deploy these faculties in a sensible and coordinated manner. People who could barely pay attention for 10 minutes in a primary school class and subsequently dropped out because of the mental strain can pay bribes and acquire a driver’s license in a few months! With their license, we expect them to stay alert and attentive on the road for 6 or 10 hours while performing complex permutations and combinations in the mind over a 500 km dark, narrow, two-way tattered stretch of a road at 100 km/h! And with tens of passengers on board in a vehicle whose fitness is uncertain! Without a comprehensive review of our driver training and appraisal system, God will certainly spend more of his time helping the Japanese overcome massive earthquakes, the Americans conquer the universe, and the Dutch reclaim the sea as our people die mercilessly on the roads. Prayers may work miracles but road safety is definitely not a miracle. We must take matters into our hands.