Kush Patel reports on the violence that occurred in Kenya following the elections earlier this year.

For many years, Kenya has been considered as a refuge for people fleeing their own country because of domestic turmoil. However, on 29th December 2007, shouts emanated from an angry throng that had gathered on the streets. Marching determinedly towards them was a battalion of riot police. Within seconds, the rioters hurled stones at the police, who counterattacked using bullets and tear gas. In other parts of the country, youths clutching machetes and sticks launched themselves upon opposing tribes. Events such as these set the scene for a blood bath that has resulted in thousands of people injured, dead or homeless. Several camps for internally displaced people (IDP) were set up all over the country. Governmental and non-governmental organisations (NGOs) such as Merlin, Medecins sans frontiers (MSF), the Red Cross, AMREF and others, deployed teams to provide humanitarian aid.

Post-election violence in Kenya results in displacement

photo source: savethechildren.org/au

Trauma victims requiring medical attention overwhelmed the medical facilities. When particularly violent clashes broke out, trucks full of injured or dead people arrived at hospitals, which in-turn became so over-crowded that patients were being treated on the corridors. A system of triage was implemented at many institutions, thus helping to treat the most severe patients first. (2,3) Patients were being rushed in with broken bones, stab injuries, blunt trauma and burns. Doctors reported certain cases where patients had sustained machete wounds that resulted in near-amputations. (3) Flying surgical teams were put on high alert, responding to violence in inaccessible regions. (4) In the worst hit areas, temporary first-aid posts were setup that quickly stabilized victims, while waiting for transport to hospitals. Any person who was critical and needed specialist care was air-lifted to the closest hospital. (3) Many of the victims were (and some still are) mentally traumatized from witnessing the violence or having lost loved ones. These people were given psychosocial support by medical personnel. (2,3)

Cases of sexual violence increased dramatically. These incidents took place both within IDP camps and outside. This will probably result in increased incidence rates of sexually-transmitted diseases, including HIV infection. Counselling and screening for sexually-transmitted infections have commenced in certain areas. (4)

Many people have been displaced and gathered at temporary IDP camps. At these camps severe public health consequences can manifest amongst the IDPs.. Four main reasons behind this are that the population is displaced, food becomes scarce, health care diminishes and living conditions worsen. Studies have shown that mortality rates are usually highest immediately after the migration. (1) Apart from the acute emergencies, an increasingly large number of IDPs need to be accommodated. At each IDP camp, tents were pitched, food and water was provided, sanitation and lavatory facilities were set up and medical camps were established. (2-6) Other essential equipment such as bed nets, (6) cooking apparatus, (3) and clothing, (2,4) was provided to the IDPs. Most IDPs had left their homes without anything. For many, important documentation was lost. Therefore, the task of registering the IDPs and getting new identification cards for them was set into motion. In order to keep the IDPs busy and lessen their emotional stress, some were given responsibilities in the camps such as cleaning. (2) Some NGOs have setup tracing agencies that help reunite lost family members.(4) Planes and helicopters had to be employed to deliver medical and other essential supplies to ill-equipped areas.(3)

The most prevalent diseases amongst IDPs are diarrheal diseases, measles, acute respiratory infections, and malaria. Additionally, many people became malnourished because of the lack of food. This aggravates diseased states and worsens the patient’s prognosis.(1) At a single camp, 541 consultations were done mainly for respiratory tract infections.(3) Most of these patients were children and many had a poor prognosis. Factors that contribute to a high prevalence of respiratory tract infections are: over-crowding, poor ventilation, inadequate shelter, and prolonged exposure.(1)
The measles immunization was provided for children.(3) For those who survive the initial illness, it can lead to malnutrition and vitamin A deficiency. Previously, measles has accounted for high mortality rates amongst children in refugee camps. However, it is less of a threat now compared to before 1990.(1)

Diarrhoeal diseases are a common phenomenon in IDP camps. Factors that contribute to their high prevalence are unsanitary conditions and unsafe drinking water. Cholera and dysentery are the main problems. In some IDP camps, diarrhoeal epidemics had broken out. These were usually treated with oral rehydration salts. However, any serious cases of diarrhoea were referred to a hospital.(4)

Kenya has a high prevalence of tuberculosis (TB) (7) and AIDS. (8) A lot of IDPs with TB or AIDS fled their homes without anything, including their anti-tuberculosis or antiretroviral drugs.(2,3,6) Adding to this, the number of patients attending HIV/AIDS clinics reduced dramatically.(3) This can have serious consequences on their health, as non-compliance results in the development of drug-resistance. Patients also become susceptible to opportunistic infections and their risk of morbidity and mortality increases.(8) One report mentioned a woman trapped at home, unable to gain access to a new dose of anti-retrovirals. As a result, when she was found by relief workers, an infection had set in and she had to be admitted to hospital.(9) Another hurdle with respect to anti-retrovirals is that many HIV patients were not getting adequate nutrition. This resulted in patients unable to tolerate their medication, further increasing non-compliance.(9) Patients with tuberculosis, face a similar scenario where drug-resistance develops.(4,7) The problem with this is that patients then require second-line drugs that are more expensive than first-line drugs.(4) Long-term effects of this may result in increased infection rates within the population. These 2 diseases were a major concern for the NGOs, who constantly held testing clinics, offered counselling and provided medication.(6,2,3) Thankfully this volatile situation has calmed down allowing people to piece together their lives. Medical attention has also improved in most areas. (6)

A correspondent from Merlin gave the following account of a typical day at an IDP camp:
The day usually starts off early, with a meeting discussing the day’s agenda. A clinic is setup wherever space is available (a vacant room or under a tree). Patients are then prioritized according to their level of urgency. Immunizations, HIV testing and counselling and treatment for minor illnesses are provided to those who need them. For those who require referrals to health centres or hospitals, transportation is arranged. Other team members conduct health education sessions for patients while they wait for their consultation.

Kush Patel
Imperial College London
kush.p.patel04@imperial.ac.uk

References
(1) Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu.Rev.Public Health 1997;18:283-312.
(2) Kenya Red Cross operations update. http://www.kenyaredcross.org/highlights.php?newsid=61&subcat=1, 2008.
(3) Medecins sans frontiers. http://www.doctorswithoutborders.org/news/report.cfm?id=2470, 2008.
(4) International committee of the Red Cross. http://www.irinnews.org/Africa-Country.aspx?Country=KE, 2008.
(5) AMREF Kenya news and press releases. http://kenya.amref.org/index.asp?PageID=10, 2008.
(6) Merlin newsletters. http://www.merlin.org.uk/Where-we-work/Kenya.aspx, 2008.
(7) O’Boyle SJ, Power JJ, Ibrahim MY, Watson JP. Factors affecting patient compliance with anti-tuberculosis chemotherapy using the directly observed treatment, short-course strategy (DOTS). Int.J.Tuberc.Lung Dis. 2002 Apr;6(4):307-312.
(8) Frick PA, Gal P, Lane TW, Sewell PC. Antiretroviral medication compliance in patients with AIDS. AIDS Patient Care STDS 1998 Jun;12(6):463-470.
(9) BBC news on Kenya. http://news.bbc.co.uk/1/hi/in_depth/africa/2008/kenya/default.stm, 2008.

Adam Briggs, final year medical student, University of Oxford.

Human resources for health are in crisis. The migration, or brain drain, of healthcare professionals from developing to developed countries is legitimised by the World Trade Organisation’s General Agreement in Trade Services and fuelled by significant push and pull factors. Push factors such as inadequate salaries, poor working conditions, and conflict all affect an employee’s decision when promised better training, higher socio-economic status, and political stability in another country.¹ Internal migration of doctors and nurses to urban areas and the private sector also has devastating effects on many poor and rural populations. Box 1 helps to put the current situation into context.

• Africa carries 25% of the world’s disease burden yet has only 3% of the world’s health workers and 1% of the world’s economic resources.²
• Between 1998 and 2002, Ghana lost roughly £35 million of its training investment in health professionals and the UK saved £65 million by recruiting them.³
• About 20% of African-born physicians are working overseas in developed countries.⁴
• Conflict only exacerbates problems with human resources for health: in Liberia, 14 years of war have reduced the numbers of practicing doctors from 237 to less than 20.⁵

Box 1. Some of the problems in human resources for health

March 2008, saw the first Global Forum on Human Resources convened by the Global Health Workforce Alliance (GHWA) in Kampala, Uganda. The Global Forum launched the Agenda for Global Action: a plan to address human resources for health problems over the coming decade, set targets, and monitor progress and accountability. GHWA was formed in May 2006, and through many programmes and publications, such as the Human Resources for Health Action Framework, it is helping countries with their health-workforce problems.^6-8

The UK based charity, Merlin (medical relief, lasting health care), ‘responds worldwide with vital health care and medical relief for vulnerable people caught up in natural disasters, conflict, disease and health system collapse.’⁹ It is an example of a non-governmental organisation (NGO) that can help to fulfil GHWA’s Agenda for Global Action. Established in 1993, Merlin has organised missions to countries as diverse as Afghanistan, Rwanda, and Honduras. Merlin’s experience in helping restructure a health workforce in countries with significant endemic problems, known as fragile states, has shown that an appropriate living wage, workforce restructuring measures, and a meritocratic promotion system are crucial issues. Their Director of Health and Policy, Linda Doull, wrote a comment in Lancet about human resources for health in fragile states.¹⁰ In the article she stressed the need for a strategic approach to tackle human resources for health crises which encompass both short-term and long-term solutions. I spoke with her to find out more about Merlin and how they’re working to reduce inequality of human resources for health in such difficult environments.

Merlin’s mandate is to work in areas requiring acute relief, and to work with the country through to recovery; they recognise that solving health problems is a long-term issue. Merlin does this through working at the level of both the community and the government to rebuild the health system.

I asked Linda what her view was on the GHWA and whether it will be effective in solving the human resources for health crisis. She believes that putting human resources for health at the top of the global health agenda is a very positive step, which will hopefully act as a catalyst for coordinated action. She compared the GHWA to the millennium development goals - often touted as unachievable but acting as a focus for political initiative.

Linda explained that there are several stakeholders that need to act to solve the human resources crisis. Ultimately, it can be argued that the responsibility rests with the government; however, does that government have sufficient investment? Governments in fragile states are often unwilling or unable to provide basic services. “Take Liberia as an example: Merlin’s budget (in Liberia) is as big as the health budget for the ministry in Liberia. Why are those distortions there? Maybe international donors aren’t willing to invest. Maybe the ministry has money, but has chosen to invest elsewhere.” She argued that perhaps NGO funding needs to be done differently. For example, perhaps Merlin needs to engage more at a national level offering technical assistance to develop curricula. “There is no one single factor, there is a mix. (We must) recognise that that (mix) has to come together and has to come together earlier. Hopefully that’s what the global alliance will help to facilitate.”

It has been suggested that the recruitment policy of some NGOs perpetuates the drain of health care professionals away from areas of need in their local health service. Merlin protects against this by advertising vacancies and vetting those who apply rather than actively recruiting staff. If, for example, a senior health minister applied for a post then they would only consider offering the job if the ministry agreed to release the minister, rather than give that person the opportunity to leave crucial local employment. Merlin prefers to work within the existing health system, with the local health care professionals. Where there are gaps in the clinics Merlin works with the relevant country’s health ministry to identify and transfer a staff member to that hospital rather than recruit staff members themselves. However, limited resources mean that staff transfer is often not easy and staff may not want to move. As an interim solution, Merlin will often employ an international health worker.

So what can we, as students, do to help? Organisations such as Merlin need volunteers who are highly skilled at both a technical level and a managerial level; senior registrars and consultants are ideal. However, as students we can still have a role. We need to recognise global health needs and be advocates through organisations such as Medsin in order to keep the issue of human resources for health on the global political agenda. As Linda says “(Medical professionals in the developed world) are very, very lucky and every health worker should be allowed to have a level of investment that makes them a competent safe practitioner, so if nothing else remember that.”

Solving human resources for health problems is a difficult balancing act. NGOs want to employ local health care workers, but do not want to relocate them from areas of health need; overseas doctors rarely provide a permanent solution. Although acute care is essential in many situations, for lasting solutions I believe that change needs to take place at an administrative level and until this happens, the problems highlighted in box 1 will continue. Local doctors should not be blamed for wanting to leave war-torn and impoverished countries but as a medical community, from students to consultants, we should be pressurising governments through NGOs and our nominated unions for better working conditions for our international colleagues.

References

1. World Health Organisation. World health report 2006: working together for health. Geneva: World Health Organisation; 2006.
2. Robinson M, Clark P. Forging solutions to health worker migration. Lancet 2008;371:691-93
3. Martineau T, Decker K, Bundred P. “Brain drain” of health professionals: from rhetoric to responsible action. Health policy 2004;70:1-10
4. Clemens MA, Pettersson G. New data on African health professionals abroad. Human Resources for Health 2008;6:1
5. Interagency Health Evaluation, Liberia, 2005: final report. http://www.unhcr.org/research/RESEARCH/456ac0682.pdf (last accessed 12/03/08)
6. The Global Health Workforce Alliance. Strategic plan. 2006. http://www.who.int/workforcealliance/GHWA_STRATEGIC%20PLAN_ENGLISH_WEB.pdf (last accessed 12/03/08)
7. The Global Health Workforce Alliance. Working groups and task forces. http://www.who.int/workforcealliance/workingroups/en/index.html (last accessed 12/03/08)
8. HRH Action Framework. http://www.capacityproject.org/framework/ (last accessed 12/03/08)
9. Merlin. Medical relief, lasting health care. http://www.merlin.org.uk/ (last accessed 12/03/08)
10. Doull L, Campbell F. Human resources for health in fragile states. Lancet. 2008;371:626-27.

In the second installment of his experiences, Paul Park tells us more about the situation in the Ugandan refugee camps

The clinic tent

An elementary school in the bordertown of Busia, Uganda housed the 2,000 refugees with each packed classroom inevitably creating a ripe environment for disease. In addition, the threat of violence was still present due to the proximity to the border and the similar tribal demographics in comparison to that of western Kenya. The Red Cross refugee site was located just 1.5 km from the local public clinic. Thus, without any medical infrastructure, Red Cross personnel were sending all refugees with health needs to the clinic. As you could imagine, the Red Cross staff was pleased to learn of my medical background and immediately gave me all clinical and public health responsibilities. I gave health education presentations (sanitation, personal and community hygiene, etc.) and continued to make referrals, in which I would write a brief history and physical to assist the overwhelmed clinic. Additionally, I initiated a patient record system. As a medical student, it is easier to feel competent when the safety net of your attending is always in place, and this scenario was no different. However, that was all about to change. (more…)