IAHPC Traveling Fellowship Report
Visit to Kijabe Medical Center , Kenya
May - July 2005
By: Beris Bird, RN
This visit was my third to Kijabe Medical Centre. It is situated about an hour’s drive north from Nairobi , and is an acute general, district hospital which provides excellent care, both diagnostic and curative, to patients who travel from all parts of Kenya seeking help. It is well known and respected throughout Kenya . Kijabe Hospital is part of the network of hospitals and clinics owned, and operated, by the African Inland Church . It is expected to be self funding and is reliant on income received from patient care, consequently, there is a constant battle to keep the accounts in balance, and annually, there is a considerable deficit.
Following the first visit in 2001, the Senior Administration made the decision to appoint a palliative care nurse in the next financial year and this happened in early 2002. At the same time, a palliative care committee was formed under the leadership of one of the senior medical staff, but this only continued to function for a year.
I was asked to return to help with the development of the service, and I suggested that it might be time to do this in the form of a clinical audit. This was agreed.
With the prevalence of HIV/AIDS there is certainly a need for palliative care to be provided in this hospital. Other terminal illnesses add to the high number of deaths which occur annually. Most of the senior medical staff are from the USA and one said to me, “I have never seen so many deaths - I just do not know what to do.”
As stated in Primary Surgery 1993; Vol 1, OUP, King M et al. (Eds), p. 586, It is a task for every district hospital. And “ No patient should be sent home – they have come seeking help, and should be admitted until such care is provided.”
It was obvious from the start of my visit, that there were many problems
“There is no palliative care in this hospital” was a statement made to me, by doctors, nurses, chaplains, - what had been started, had not continued as planned.
The fact that the need was great was obvious from the condition of the patients and from the concern of many staff. A letter written to the Accord staff by one of their terminally ill patients reads, “I have gone through a lot of stress since I got sick. My parents deserted me and told me to move out of their compound. Nobody else wanted to stay with me because they all thought I would infect them. Now I cannot provide for all my children’s needs. Most times they go to sleep hungry, never go to school, and sleep down on the floor. We are really suffering. Since I am not working and there is nobody to take care of my children, is there any possible way for the Kijabe mission to take them and help them? I also want to know if there is any way I can learn to help other people who are sick? I want to work for them because I know they are as desperate as I am. I have always wanted to work with sick people though it is unfortunate for me to be sick too.”
One young girl , in the terminal phase of HIV/AIDS, not only had active T.B, but had Karposi’s sarcoma and lymphoma - she was in constant pain, was being put out of her rented home because of her condition, and simply, had no where to go.
Cancer is fast becoming the forgotten disease in Kenya as the focus everywhere is on HIV. Two young men came to the hospital seeking help, Peter, 23 , orphaned some years ago and was being cared for by elderly grandparents. He presented with gross ascites which required paracentesis every 3-4 days to relieve symptoms and to help him to breathe. His grandparents could not pay his expenses and so simply did not visit. A diagnosis was made at laparotomy of non-Hodgkin’s lymphoma. In the West this is curable, but for Peter, chemotherapy was not an option – his condition was too advanced, his family too poor to pay.
Problems for palliative care – how to discharge home, how to arrange for paracentesis in a rural setting, how to help the grandparents meet the costs of his treatment and to understand that their grandson was to die? These needs were met, but only because a fund had been set up to help in such circumstances.
Stephen, 21, had had a palliative amputation of a sarcoma of his femur two years previously. He had a supportive family, but they lived many miles from the hospital and could not afford to visit or to pay for his care. Stephen presented with multiple secondary tumours in his lungs and with acute dyspnoea needing continuous oxygen. He had severe pain and was wanting to go home. But, how?? His symptoms were eventually controlled, but his condition continued to deteriorate and he died in hospital. His death left his parents with bills they just could not pay and with a grief they could not share because they felt they had abandoned him.
Much is being done for these patients. The Accord project was set up with the aim of giving registered HIV patients antiretroviral agents (ARVs). It has made a big difference to the condition of many patients, giving them improved health and the ability to work and to care for their families. This means that children will wait longer to be orphans! But still, there comes a time, a time to die. And then what??
In Kenya, the Nairobi Hospice is very active in encouraging the care of terminally ill patients through their palliative care educational program. There are 9 agencies in Kenya, now registered with the association – Kijabe being the only one to offer inpatient care. Not all people can be cared for at home, too often this assumption leads to ‘home based neglect’.
At the end of my two months visit, many of the problems had been addressed and the hospital administration was ready to support more appropriately the development of palliative care in the hospital and to support the staff.
The hospital mortuary gives an excellent service to the families of patients who die, both in the hospital, and in the community. In Kenya , there are no funeral directors, and the burials usually take place on family properties. The hospital mortuary gives ‘refuge’, sometimes for weeks, as arrangements, practical and financial take time.
Internationally, the Declaration of the Seoul Conference, March 2005, stated,
“1. That all governments should include hospice and palliative care as part of the government health policy
2. Access to this care should be seen as a human right.
3. Barriers of laws and of regulations and of cost, regarding the use of opioids, and specifically, morphine, should be eliminated.
4. This care should be available to all citizens in the place of their choice, be in home, hospice of acute hospital..”
A very big problem in developing countries is the “How’!! The provision of palliative care is a challenge for this hospital, but it requires above all else, money!!
For people in Kenya , dying is compounded by total suffering, the misery of poverty, the misery of not being able to get help, but most of all, the misery of not being able to afford analgesia – this is the pain of poverty, the pain of dying, which we seek to alleviate.
Very few agencies are prepared to support the work of a district hospital, and so when there is no government assistance, and no health insurance system, it becomes impossible for the very poor to receive the care they need in a terminal illness.
The Accord project has demonstrated the powerful influence of money!
Hospitals can be willing, staff educated and available, in patient care offered, drugs subsidized, but without adequate funding the Palliative care services will be limited.
The commitment of the International Association of Palliative and Hospice care through the Traveling Fellowship grants is one way of supporting the development of services in countries where funds and resources are limited. Education is only part of the problem, money remains the one component which it seems impossible to change .The poverty of the patients, and poverty of health care facilities simply prejudice against patients in these countries being able to die with some care, some compassion and with some alleviation of their suffering.
It was very helpful for me, personally and professionally, to be supported by the IAHPC. I would like to express my thanks to all concerned.
IAHPC Traveling Fellowship Photos
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Many Maasai come to the hospital - Aids is a big problem - education and management of the disease very important part of care
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Sometimes, all that can be done, is to be there! |
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| There is a program supported by hospital staff to give care and food to ladies who have been widowed through Aids, or who are caring for grandchildren and have no means of working for a wage |
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| Home palliative care in HIV/Aids - very poor conditions. |
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Hannah, dying of cervical cancer. She was admitted because of physical symptomatic needs, and because she could not be cared for at home. The foul smelling discharge from the cancer, had caused her to be sent away. I was able to involve the nursing students in her care, and much was done, and learnt. The smell was controlled with metronidazole tab lets being crushed on to the dressings, and with frequent washing of the area. Her mouth care had been ignored, and the students care made a great difference to Hannah's comfort. They learnt a lot! Most important perhaps, was the satisfaction they found in caring and being able to help. |
Beris M Bird, RN
Mt Martha, Australia
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