Tag Archives: Health care

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.

ebola map
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.

ebolavd
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.

mpdb_logo

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.

Quality Medical Care Begins with You: The Patient

In recent days, there has been much talk in the public space concerning the general subject of quality of healthcare in Kenya. The discussion, unregulated and undirected, has generally pitted health workers on one side against the public on the opposite side. The media and a motley other organizations including the KMA (Kenya Medical Association), KMPDB (Kenya Medical Practitioners and Dentists Board) have found themselves somewhere in the middle-ground and often drifting to one of either sides to advance their points. Pointedly, there is absolutely nothing wrong in the various interest groups drumming up to their tunes; it is their duty to inform either side of why things are as they are. As long as a modicum of objectivity is maintained, this kind of engagement is as healthy as it is necessary.

Curiously, not the entire public is involved in this discourse. It is the ‘aggrieved’ public whose voice is loudest. These are relatives of people who died or suffered injury in circumstances that were less than satisfactory in their eyes. While I empathize with this group as an individual who has also lost a parent in similar circumstances, I am alive to the fact that such loss and the attendant emotion often do not make for an objective background upon which a critical evaluation of a system can be carried out. Nevertheless, that does not negate the import of such claims. On the other hand, those silent cannot expressly be presumed to be at peace with the quality of care in our hospitals, neither can we assume they share the sentiments of the aggrieved public. Their silence in a matter of life and death is to say the least disturbing. Archbishop Desmond Tutu once said, “If you are neutral in situations of injustice, you have chosen the side of the oppressor. If an elephant has its foot on the tail of a mouse, and you say that you are neutral, the mouse will not appreciate your neutrality.” It is this silence from the rest of the public that is my concern.

Politicians, loud and macabre as ever, have shouted themselves hoarse at us with Bishop Tutu’s timeless quote when galvanizing support for their causes; noble or otherwise. There has never been a shortage of takers to this call; young men, women and people of all walks of life have taken part in political discourses of one type or another as a way of dispelling even the mere thought of their neutrality. The commendable pinnacle of this national duty has been the electoral process; a period during which the country literally grinds to a halt as people queue up for hours to vote and diligently keep tabs on the counting and tallying process for days on end. Indeed, until the winners are declared (or even sworn into office), it is not over. I am least suited to explain the reason for this kind of enthusiasm.

The average voter has little grasp of the technical details of democracy and governance; not unlike the average patient’s grasp of the technical details of medicine and health. In both cases however, these two individuals clearly understand what they want of the process. The voter may have no more a reason to vote than to put their tribesman in office in the same way the patient may have no more a reason to visit the hospital than to have a safe delivery, surgery or relief from a nagging headache. It is for the professionals to sift through the tomes of theory and practice in order to meet the client/patient at their point of need. This interaction between technical expertise and client demands is the basis of quality. For historical perspective, I will quote a 1988 article published in the Journal of American Medical Association (JAMA) by Dr Steffen Grant that defines quality of medical care as “the capacity of the elements of that care to achieve legitimate medical and nonmedical goals.” It is instructive to note the word ‘elements’; as this signifies a system of multiple components. The healthcare system brings together health workers, medical infrastructure and clients: management and finance play overarching roles to enable the first three components achieve legitimate medical and nonmedical goals. It is therefore preposterous and sensationalist, nay defeatist, to blame lapses in quality of care on any one of the components without giving the rest a fair share of scrutiny.

nurse-waiting-room

While it is obvious health workers need proper training and skills with appropriate medical tools and equipment as well as a well-financed and managed system to be most effective in their trade, the role of the patient is seldom emphasized. Without the patient, there would be no need of a health care system in the first place. Patients have the pride of place as consumers in the health system. It is for them that everything else in the system works. It is therefore incumbent upon patients and their carers to not just be passive goods on the health conveyor belt but active participants in every stage of the decision process. The best time for any patient to make a contribution to the health system is not when they lay prostrate on their hospital bed; it is when they are healthy, strong and able. That is to say, we all have a duty to improve the quality of care in our hospitals. We must demand to have our hospitals staffed with enough qualified personnel. We must demand that these hospitals have running water and electricity as well as the appropriate equipment. We must demand that the system is well financed to handle emergencies without asking for money beforehand. We must demand to have a working health facility within no more than half an hour’s walk. If we leave these demands to only doctors and other health professionals to make, we shall continue making unfounded and salacious claims (of 30% of patients dying of poor care and 10% of all patients being misdiagnosed) as have been carried in the print and electronic media recently.

It does not make sense that a poor Kenyan will prepare a makeshift bed in his living room for an overnight visiting friend but accept to share a bed with a sick stranger in hospital! Why should anyone have to sit in a queue at the hospital for 30 minutes? Or have to walk in labour in the rain, in the dead of the night for 2 hours to reach a hospital? The same energy we exhibit in showing our love for politicians, music, dance and enterprise must be directed at advocating for quality of care in our health system. The doctors have done their part in exposing the problems; you must do your part in demanding for better from your leaders at the grassroots to the President. And in the inevitable event that you fall ill, be forthright and candid with your health provider: amicably share with them your pain and agony and help them meet your needs; medical or otherwise.  They will be in a better position to prioritize your legitimate needs and make a sound plan of action. Even then, ask questions and get answers; every doctor is trained to listen to and act on their patients’ concerns with humility and empathy. Should this not happen, speak out about it even if you suffered no obvious loss. This is the only way to better healthcare; all players of the system pulling in the same direction openly, frankly and with unity of purpose.

Finally, the mass media has the unique role of arbiter and educator. As the late Paulo Freire, an internationally acclaimed 20th century thinker and educator, once said, “The educator has a duty of not being neutral.” The media must highlight failings of each of the components of the system with equal zeal. Without trying to appear irrationally optimistic and escapist, I know for certain there are positive stories of doctors, managers and other players in the system who are selfless and going beyond the extra mile to make healthcare in Kenya of better quality. It is not a waste of space to mention these in the media.