Karen Bevan-Mogg / General Practitioner / London
Dr Karen Bevan-Mogg is a UK GP who has worked around the world in remote settings, through NGO and expedition work. Here she writes about travelling to a refugee camp in Kenya with Primary Care International. The aim? To teach health care colleagues in low and middle income countries about non-communicable diseases (NCDs) such as diabetes, cardiovascular disease, asthma and COPD. NCDs are becoming a huge burden in the developing world and PCI is currently recruiting NHS GPs to help deliver relevant and focussed education to community health workers. Read on and get involved!
For 90 minutes we fly north from Nairobi, over ridge after ridge of bleak mountains dotted with scattered bushes, scarred by dry river beds. There is no evidence of human habitation – no roads, no villages, no mines, no agriculture – until we bank sharply to the left to begin our descent. Then I see it: Kakuma camp. Hundreds of corrugated iron roofs, gleaming in the sun, arranged in regimented lines, home to 187,000 people waiting for a better life.
‘Kakuma’ is the Swahili word for ‘Nowhere’. The camp sits next to a small town of the same name, in a remote area close to the borders of South Sudan and Uganda. The region is largely overlooked by the Kenyan government, which is much more interested in the productive farming country around Nairobi and Mt Kenya. Our short drive from the rough airstrip to the UNHCR compound demonstrates how diverse the population has become, with scantily clad local Turkhana people mingling with covered Muslim women and robed men from many nations. The majority are Dinka and Nuer people from South Sudan (between whom civil war broke out after independence); Ethiopians, Congolese and Somalis are the next largest groups, with a few Ugandans, and, increasingly, since the recent disturbances, Burundians.
I am here with two GP colleagues, Peter and Sarah, to support the International Rescue Committee (IRC) staff who provide health care for the camp and the local Turkhana. Although malnutrition and infectious diseases are still major problems, non-communicable diseases (NCDs) such as diabetes, cardiovascular disease, asthma and COPD now cause around a third of all deaths. In low and middle income countries NCDs cause more premature (<60yrs) death and disability than HIV, tuberculosis and malaria combined.
This shocking reality is the result of years of neglect by the international community (diabetes and hypertension aren’t sexy) and a lack of experienced clinical staff in settings where infectious diseases and acute medicine have historically been most significant. So our task is to deliver four workshops for doctors, nurses, clinical officers and Community Health Promoters (CHPs), to improve their understanding of NCDs and offer clinical and strategic guidance to improve prevention and patient care. We’ll follow-up with further dialogue and CME remotely.
Most NCDs are the result of lifestyle choices, or lack of choices if you happen to live in a refugee camp. How do you talk about the effects of smoking with a man who has lost everything except the clothes on his back? How do you advise a mother cooking World Food Program rations for her family of 12, about a suitable diet to help her diabetic sister and reduce everyone’s cardiovascular risk? I struggled with our position while I prepared for our first trip 18 months ago, when we worked with staff in Jordan’s Za’atri camp, for Syrian refugees. However, drinking (sweet) tea with a middle aged man whose diabetic toes had already been amputated and the stories told by countless doctors and nurses whose families have been affected by NCDs, convinced me that prevention and early treatment in the community is crucial –both clinically and financially to manage this growing epidemic.
Kakuma camp is divided into four sections, which consist of Zones and Blocks. Each section has an outpatient Health Centre, staffed by a clinical officer and a nurse, to deal with non-urgent cases and provide antenatal care. Emergencies and further outpatients are seen at the 130 bed field hospital, staffed by doctors and nurses.
Wherever we go, we try to understand the reality the staff are working in, by seeing as much as possible of the clinics and communities, and by meeting as many of the team as we can. I’m always humbled by how much our colleagues accomplish in the face of enormous challenges and Kakuma was no exception. The old Field Hospital is staffed by young, relatively inexperienced staff who (understandably) seem overwhelmed by their considerable burden of clinical responsibility. Access to basic diagnostic tools such as x-rays, ultrasound and lab tests, is very limited and senior supervision and referral opportunities are restricted to occasional visits from specialists. It is possible to fly a patient to Nairobi, but this is expensive and difficult, and amongst so much need deciding who should stay or go is tough.
Peter and I squeeze into a minibus with Community Health Promoters doing the polio vaccination campaign, to visit Zone 4, the newest section, where recent arrivals live. As we bump along, Patrick, a very tall, smiley Nuer, explains that they have vaccinated 48,000 children so far and there’s just one day left to reach the 60,000 target.
Q – How do they know who’s already been vaccinated?
A – They paint henna on the little finger nail, which lasts the length of the campaign.
Patrick arrived in Kakuma 10 yrs ago and was trained as a Community Health Promoter by IRC. Each CHP is responsible for delivering health education, collecting information and liaising between the health teams and community, giving them a crucial role in the struggle to prevent and treat NCDs like diabetes.
Zone 4 is ‘overflow’ zone, as the camp was designed for 100,000 refugees but currently holds 187,000 and is growing. Negotiations to extend further were underway between the Turkhana people and the Kenyan government while we were there. Dada’ab camp in Garissa county (to the east) is slowly emptying, forcing refugees who cannot return home to shift to Kakuma instead. Zone 4 is barren, dusty and divided into plots which each accommodate 2 huts, typically one for cooking and one for living in. A typical family of up to 18 people will be allocated their plot on arrival, given the tools to make earthen bricks and corrugated iron for the shiny roofs we’d seen from the air. Together with dry acacia-thorn fencing between plots and a complete absence of greenery, the resulting environment is far from welcoming.
In contrast, Zone 1 opened in 1992 and feels more like a village than refugee camp. Mature acacia trees and bushes provide some shade. The small brick houses have been grouped into households as families have expanded. At the centre is a thriving market area of small businesses selling most daily essentials: maize flour, plastic chairs, onions, even a place to charge mobile phones. We bought avocados and tomatoes from a grocer who told us how he had left Burundi in 2007 as an adolescent and gone to Nairobi, where he worked in a hotel and tried to study in his free time. Last year the Kenyan government insisted that all refugees live in camps, so he left everything once again and came to Kakuma. He and two compatriots make a living from the shop, selling washing powder, rice, maize flour and a few fresh items in the tiny quantities that people could afford with the little money they have.
‘I like it here with my friends; they are my brothers now,’ he said. ‘We are like family.’
Life is far from easy though. Ethnic conflict is a constant threat to security. Cattle rustling between refugees from different tribes, and between refugees and the Turkhana locals, results in more bloodshed. The climate is harsh. Most months are unremittingly hot, dry and dusty, but in January and February torrential rains fall on the mountains to the north and west, and pour huge volumes of water into the empty riverbeds, which are rapidly overwhelmed. Every year the camps (and the UNHCR offices) are flooded; houses, people and animals are swept away. Malaria flourishes in the pools left behind as the waters recede. Most refugees have set their hopes for the future on ‘resettlement’ – the good fortune to be offered sanctuary by countries such as the US, Canada or Sweden (but not the UK, incidentally).
So with all this in mind, we spend the next eight days with all the available clinical staff in the sticky IRC and Lutheran Worldwide Federation staff canteens, conducting training about chronic diseases. Most know the theory but applying this to the reality of camp life is difficult. What practical advice can you give a 50 year old Muslim woman living in Zone 4, who needs to lose weight in a culturally acceptable way? How do you store insulin in 42 degrees heat? We introduce single page ‘Field guide’ summaries of evidence-based best practice, adapted to the camp setting to include the tests and drugs available (WHO Essential Medicines). These are used to discuss numerous case scenarios, which never fail to generate colourful discussions and ideas. Role plays are sometimes drowned out by the hefty canteen freezers but prove useful for practising consultations skills. Examination of the diabetic foot using home made ‘monofilaments’ (broom bristles of appropriate weight) takes place in the staff ‘chill out’ area by the pool table.
We have worked with partners in Jordan, Burkina Faso, Kenya and Somaliland and seen everywhere that the concepts involved in NCD care aren’t new: the need for the patient to understand their diagnosis; the importance of taking a good clinical history; the ability of nurses to share clinical tasks; the lifelong partnership between doctor and patient; the possibility of managing NCDs in the community instead of at hospital level; the ‘impossible task’ of educating patients and communities. None of this can happen if clinicians are not supported by the system they work in. So the health care teams also consider appointments systems, records, patient flow, staff training, data collection, audit, significant events (and all the other tasks we love to hate at home) as part of ‘the bigger picture’ influencing NCD care. In Somaliland and Jordan we worked with MoH officials and a ‘focal team’ of doctors to develop strategic ‘road maps’ for change, and trained some as trainers (ToTs) to cascade the learning to their peers.
In Kakuma Sarah spent time with the CHPs, focused on understanding each of the chronic conditions and teaching techniques to help patients change lifestyle behaviour, rather than simply delivering health education messages. At first, only one could think of someone he knew with diabetes. By the end of the course the majority realised that NCDs are causing disease in their block.
It is never satisfying to leave after a short visit. I always want to stay longer to support staff as they practise new skills in their clinics. Instead, as our new friends return to work, I find myself back at the gravel airstrip, waiting to board the World Food Program flight back to Nairobi. Turkhana women walk on the other side of the perimeter fence, with their brightly coloured neck beads and clipped hair (short at the back and sides, long and braided at the crown, to accentuate their long necks). The men wear a cloth draped casually over one shoulder and sport ostrich feathers on various pieces of headgear. They only recently started wearing ‘western’ clothes, just as some have abandoned their nomadic way of life to settle, for the children to go to school.
The Turkhana are a people in transition. Their dislocation from a traditional way of life will undoubtably be accompanied by problems, including the onset of NCDs. It is up to us as an international community to combat this threat with simple prevention and affordable care, so that future generations everywhere can look forward to a bright future.