the Journal 4
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IMPACT Kenya, community health to reduce preventable disease

We were warmly greeted on arrival at Mwea and the very competent and experienced nurse in charge, Sister Eliana, happened upon us as we were trekking the 2km up to the hospital from the main road. To be brutally honest we had few expectations of the role we were expected to adopt nor the projects with which we were to participate in. IMPACT is an international medical charity that aims to reduce the incidence of preventable conditions and disability by early identification of problems and by running frequent surgical missions using specialist doctors in the two rural clinics they are affiliated to in Kenya. The hospital appeared clean, well staffed and accessible on first impressions and we were kindly given a guesthouse for our stay.

The funding received from IMPACT had been used for community health monitoring programs and to support three public health nurses that trained members of the community (from womens’ cooperatives to school children) in identification of diseases and basic health care.

The school monitoring scheme was still in its infancy. It had yet to be applied to an adequate proportion of the local primary schools in the area covered by the hospital. Immediate results from the schools in which the nurses had selected and instructed health monitors became evident when we visited schools where there were no community health visits. Not only did the pupils from the health-trained institutions have 100% positive TB immunisation scars, but also the incidence of infectious and non-infectious conditions appeared to be consistently below that of the schools not participating in the scheme. Dental caries and ringworm, a contagious fungal infection, were the most common complaints and the system of referral of potential patients to hospitals - rather than for bed-rest or to a traditional healer - was valuable and only occasionally ineffectual (when the cost of treatment was unaffordable to the parents or minders).

The situation that became most familiar as we ourselves identified and visited those in critical need of medical care was the inability to afford the treatment, even if it was subsidised by the Mission Hospital. The principal reasons behind this incapacity to budget for medical treatment in the families around Mwea were multifaceted.

Firstly the effect of provision of free primary education in the country from 2003 onwards has had repercussions beyond increasing the number of children attending schools and class size. The assumption that all costs were covered was very strong and so parents were generally unwilling to give any funds for additional fees that were mandatory for the head teacher to cover such as examiner’s salaries. Therefore further requests for a small donation to assist those that needed medical assistance through the school would not only be unpopular but probably unfeasible. Although there was concern for the health of the school members on the part of the teachers, occasions where a child received financial help with medical fees were rare.

Secondly the vast majority of the families in Mwea are not land-owners but work on rice estates owned by a few wealthy individuals that pay a very low wage to the workers. There is simply not enough free household income to set aside sufficient funds to cover medical expenses when they arise despite the relatively low charges for treatment and laboratory testing at Mwea Mission Hospital.

Lastly there seemed to be no community medical assistance provided by the political leaders in the villages. Whether this is due to inadequate organisational structures and an unwillingness to initiate a donation scheme to support members of the community that are unable to cover medical bills alone or due to a partial reliance on external organisations for aid is a moot point.

One point that was emphasised heavily when we asked what would improve school health quality and education was the need to supply first aid kits. This very simple way to bring immediate medical relief without resorting to hospital care also instils stronger personal management and institutional responsibility for the health problems of the school. The cost of first aid kits amounts to around £10/school and there are 51 schools in the Mwea region and 215 schools in the Kibwezi region. In addition to the initial outlay of funds to buy the kits they of course need to be maintained which costs about a further £5/kit/year. The community health nurses would be responsible for installing the kits and teaching first aid skills to special needs teachers and health monitors, so that adequate and effective treatment can be given.

We began working at Kibwezi after a brief visit to Uganda and were struck by the focussed approach at preventing and treating disease and their promotion of environmental management from within their own community. The ability to instil a sense of responsibility after implementing a reforestation initiative is not an easy task for a group of one or two community health workers. The success of the schemes will greatly rely on the organisational and leadership skills of the political principals and village elders to motivate people to persist with projects. Many of these undertakings do not have immediate benefit but are vital for the future health of the land of the inhabitants.

Our work at Kibwezi was a little more varied than at Mwea. The school health checks were still an important part of the community projects, and we found ourselves on several occasions visiting schools in the local area to dispense medicines such as de-worming tablets and to monitor the basic physical condition of the children. Our role on this occasion was not only medically related, however, and on the Saturday morning we found ourselves with digging tools in hand and a number of trees to plant. The tools provided were not quite what we were used to, being roughly fashioned from tree branches, and our delicate hands were soon riddled with blisters. Despite our discomfort we successfully planted thirty-four trees within the compound of the Mission hospital left under the care of the health workers. Although this is a drop in the ocean in the battle against deforestation and all the problems that result from insufficient wood for fuel and timber, the hospital plantation is to act as an exhibition plot to be replicated on a much greater scale out in the rural areas. Of the seedling plantations we visited there was a real concern that each tree was given to responsible people with at least some idea of how to care for it until it reached maturity and started benefiting the community. The hope is that the communities will set up their own seedling nurseries for trees and vegetables to be entirely self-sufficient in their planting for the future. We observed a definitive drive towards self-suffiency in the communities and not the long-term reliance on outside aid that is often associated with such projects.

After the two placements in Kenya that were all too short we hope to have come to understand a little better the direct effects of aid donated to IMPACT and the areas that are in desperate need of further support. The accountability offered by IMPACT in their expenditure of donated aid was very good and most of the staff and all of their surgeons operate on a voluntary basis. The next step is to drive down through Tanzania to Malawi where we are expected in Open Arms Infant Home towards the end of the month. The bus is handling well after a worrying problem with the brakes was sorted with a bit of innovative mechanical improvisation and we feel fairly confident that the conditions of the roads will never get too be unpassable from here down to South Africa.