DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance.
Date of interview: 6th May 2020
Number of confirmed cases at time of interview: 490
Number of deaths at time of interview: 24
Population: 51.4 million
This week I am speaking to Dr Joy Mugambi of Kenya. She is the first doctor from the African continent that I am speaking to and I have so many questions to ask her. I have encountered Joy from a distance at WONCA World in Seoul a year and a half ago when I listened to her talk as the President of the Young Doctors Movement of Africa, Afriwon. That speech really remained with me and, a year and a half on, I was finally able to tell her in person how inspired I was by her words. Interestingly, I feel the same in this interview. Normally, when I have been interviewing for this COVID-19 series, I make written notes on which I base my blog post but with Joy, she has a very distinctive way with words; I don’t know if this is particular to Joy or to Kenyans but I chose to put down my pen and hit the record button. She has a way of making you sit up and listen.
We begin by talking how different her world in Kenya from mine in the UK. Joy works as the only family physician in a rural hospital between Nairobi and the Ugandan border. The other doctors in her facility include an obstetrician, an orthopaedic surgeon and a general surgeon which means that anything not related to maternal health or some form of surgery comes to her. As she puts it “I can do everything they do but they can’t do most of what I do.” As with many rural health institutions, distance is a real issue. The county is large and the terrain is difficult with the next physician (and incidentally the closest four ICU beds) being 200km away. This is a far cry from my London clinics where the closest hospital will always be about 20 minutes away.
Through these interview series, I’m seeing that disaster preparedness is one of the key features of success. Kenya faced the real possibility of Ebola invading its borders two years ago and they did a lot of preparation. For Joy’s hospital, they are near a highway that leads to Uganda so there was every chance that this could have been a local reality. But since Ebola never arrived, everyone understandably relaxed their infection control measures. Some regions had stocked up on hazmat suits but, after two years, were now using them for other activities that weren’t related to infection control. Like the rest of the world, initially Kenyans assumed that COVID-19 was like the flu and came off the starter blocks slower than they should have, much like the rest of us. When their first case was reported, they only had 200 ICU beds nationwide, no intensivists and no ICU nurses. Prevention was the only choice. Joy had sensed some urgency when the epidemic was brewing in China and had urged her hospital to resume pandemic training in January. The world is a global village and it was only a matter of time.
With only four other doctors to serve a population of 130,000, this was going to be challenging. Luckily she has a fantastic group of clinical officers – 21 to be precise. Clinical officers are like physician assistants and assist in running the chronic care clinics and the emergency department. The accidents and emergency clinical officer has a higher diploma in anaesthesia in addition to a Bachelor’s degree in clinical medicine thus serves as a great support to the emergency department. She has split the team into three so that one team can work and then take two weeks of rest. This has meant that her staff are well-rested but also means that if one team falls sick, there are two teams waiting in the wings to take over. Joy proposed this measure to protect the staff, when one hospital in Nairobi had to close its doors due to their health workers getting COVID-19; she is glad the bosses listened and implemented. They continue to do weekly debriefs to ensure that the staff stay updated which has made a big difference to the fear factor.
Talking to Joy, their criteria for PPE seems to be the same as the UK – surgical masks and protective clothing normally when seeing patients and N95s when switching to Aerosol Generating Procedures (AGP). Admittedly, they have a stock of hazmat suits which we don’t and also, very excitingly they are designed testing boxes that have been used in South Korea to do testing. She says that the introduction of the boxes has helped to ease some staff concerns about getting close to patients with COVID-19 symptoms. The other positive to using the boxes and to the strategy of rotating staff is the slower burn rate of PPE as there are less staff to use them and less interactions that require them – essential when resources are limited.
As if timing couldn’t have been worse, Joy’s local area was hit by rain and floods in April and May and much of the local infrastructure was damaged. On top of the local banditry and internal clashes and the floods, she could only hope that COVID-19 would take its time to get to her shores because there was no way her resources would stretch. Should she be searching for quarantine cases? Should she be trying to control the chronic diseases? Should she be managing the villagers that have been internally displaced? There is so much going on in her mind that she can only survive by compartmentalising and hoping that things don’t get out of control.
I ask Joy about community engagement. At the moment, in the UK, we are having to deal with the fact that many patients are afraid to come to the clinic or to the hospital and it’s difficult to know how to move forward from this. She also noted that some patients had initially taken off from the hospital in fear, but they started to work with their community health workers (CHW’s) and local leaders to explain to them their strategies. When Joy became the local doctor four years ago, she realised that, for anything that needed to be done by the community, it needed to go through their tribal leaders and elders. Being female and not a local resident takes time to be accepted as Joy says, but she now has their blessings and runs monthly meetings about sexual and gender-based violence where police officers, religious leaders, chiefs – essentially all the key people of that community – get together and try to find a mutually beneficial strategy. This has meant that Joy could use these networks to disseminate correct information about COVID-19 to the masses. They have regional Whatsapp groups where, if anyone hears anything in the community such as at the market, they can post on the Whatsapp group and ask if it’s fact or fiction. The tribe leaders have become mini-experts in themselves and are able to work through a lot of the fake news. This community engagement was particularly important at the beginning of the pandemic when the community needed clarification about the Chinese contractors who were working on a local project. Given that they had returned from holiday for Chinese New Year, there was some suspicion about their health status. Joy screened them and ensured that they self-quarantined for 14 days and the community re-accepted the Chinese workers back into their fold. What I am seeing here is that community engagement is removing fears, but as Joy says, it has taken time to become a trusted member.
This patient education has been very important in encouraging social changes to mitigate the spread of covid19. We have all learnt from Ebola where the public strategy was criticised for banning traditional funeral rites which created a lot of friction between public health officials and the locals of West Africa leading to underground burials. Joy has been using her local networks of CHW’s and local leaders to explain the logic behind the strategies which has been slowly cascaded down. Patients only come when they need to and they stand 2m apart when they queue. Her community loves social interaction and the physical distancing is alien to them. “Standing 2m apart where I work is like speaking French to someone who has never spoken French.” This reminded me of last week’s interview with Dr Ilyas Erken from Turkey, where he felt like he was killing his patients by telling them to stay at home because being sociable is part of everyday culture. In Kenya, a handshake is everything. The elderly patients are finding it really hard as they cannot give hugs and they also have had to stop the physical act of giving their blessing by spitting on your palm. All this has had to go. Whenever the staff has to tell them that they can no longer handshake, it is evident that everyone is really struggling.
Further afield, to minimise travel to the main hospital, Joy has proactively asked her rural Community Health Workers (CHW)’s to assist. There is an existing community diabetes and hypertension programme with retinopathy screening, which means that those with chronic diseases are already on a register. She has asked the CHW’s to link the patients into their nearest facilities, to enquire if they have sufficient drugs and whether they are sick. Those who need further care have been referred to the hospital, but otherwise the rest are managed at home where possible so that they don’t have to travel large distances to pick up medications ensuring less patients at the hospital. To minimise congestion in the hospital further, Joy has introduced a several-stage triage system starting at the front gate. The security officer registers anyone who walks in at the front gate allowing only the patient and one caretaker to pass. Although it was common practice for mothers to bring all their children in when consulting, they have adjusted this so that only the mother and the sick child can come in too. Once through the gate, everyone has to wear a mask and there are facilities to wash their hands. They then move to a tent where they are screened for a fever and a brief history is taken. There has been two clusters in Kenya so the travel history needs to cover both places. If they have any risks, they are moved to the holding area where clinicians wear full PPE and these patients are screened. This is done in the COVID-19 boxes popularised in South Korea and reduces the need for masks and hazmat suits. They also test their sputum for TB and Joy is very pleased that they have picked up four extra Multi-Drug Resistant TB (MDR TB). Small wins for public health at the time of COVID-19.
What really stays with me after this interview is that Joy points out that this novel coronavirus of 2019 has brought all of us to our knees and I cannot disagree with this. I’ve been thinking that it hasn’t mattered whether we are from a rich nation or not, we have all had to face up to the same disease and the same medical, social and economic woes. Does this mean that, post-corona, the narrative of global health will change? We have long been accustomed to the paradigm of the global North knowing better than the global South which are, broadly speaking, drawn along post-colonial lines, but can we continue to perpetuate this when Europe and the U.S have been the hardest hit across the world? Joy talks liberally about the lack of resources in her country, but it really strikes me that her and her colleagues have made up for this with an ability to think innovatively and outside the box, whereas we, in Europe, have supposedly all the resources in the world but don’t know what to do with it. How comes we haven’t been able to practise what we preach? Whatever the outcome, the post-covid world will, without doubt, be a different landscape to what we have been used to in 2019.
Thanks to Joy for her time to be interviewed. I really enjoyed learning from you and I look forward to hearing you speak again!