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Involve community health workers and village leaders to facilitate emergency medical attention during curfew

By Stanley Aruyaru | April 5th 2020

The Alma Ata declaration of 1978 underscored the importance of Primary Health Care (PHC) as a component of Universal Health Coverage. In Kenya, a signatory to that declaration does value the role of PHC in healthcare delivery. As such, our health care system is arranged in 6 levels of increasing volume and complexity. 

Level 1 is composed of the community health volunteers incorporating the community members. The dispensary is at level II; Health Centre is Level III, with the Subcounty Hospital being level IV. The County Referral Hospitals are at level V while level VI is composed of national referral hospitals. 

The existence of such an elaborate system enables the country to have a clear chain of command and communication when dealing with outbreaks (whether communicable or not). 

Level I health workers form the backbone of PHC. They collect data on births, deaths, and a retinue of health parameters covering every household in their communities in liaison with the government administrative officers. It is such a beautiful system. 

When health emergencies occur, we should not sideline such a system and demand a new one. We should just beef up our existing system. That is what should be the case in light of the COVID-19 pandemic. The formation of the COVID-19 Emergency Response Team does not torpedo our existing system. It gives them a clearer chain of command and a heightened sense of urgency. 

In light of the dusk to dawn curfew imposed by the government of Kenya as a containment measure for the pandemic, most Kenyans are left in a lacuna of how to deal with medical emergencies occurring at night. 

The big questions remain: 

What happens in the event of an accident at home (children falling off stairs, suffering burns), or a heart attack? What about the lady who goes into labour? 

Is there a number to call?

Are there enough ambulances to take them to the hospital and back? 

Does the patrolling police officer act as the triage nurse and determine that someone is seriously sick/injured and needs to allowed to proceed to the hospital? 

Do we postpone seeking medical attention until 5 am?

I had wished away these questions and worries. When I posted them on social media, I was shushed. I was told the healthcare workers are essential services and are permissible to travel during the curfew.

Those of my friends in the law enforcement agencies told me there are means in place to ensure those in need of medical emergency are allowed to go to the hospital even during the curfew. 

As Alexander Pushkin observed, a deception that elevates us is dearer than a host of low truths. The low truth is that most healthcare workers do not know what those measures are that are meant to ensure those in need of emergency medical attention during the curfew can feel comfortable to stray out of their homes to the nearest health facility. 

One of the Kenyan media outlets has published a story of a pregnant woman who needed such attention. She summoned the only available means of transport in rural Kenya- the ubiquitous boda boda. When the boda boda rider was getting back home after dropping the expectant lady at hospital, the media house reports, he was clobbered by the police as he was breaking the curfew. He has succumbed to his injuries. One hopes that this is not true! 

That means the next boda boda rider will not come out to take the next patient to the hospital.

Sadly the next patient may be one suffering stroke with just a two-hour window to reverse brain damage; waiting till 5 am will mean death or permanent paralysis. It could also mean the pregnant mother with obstructed labour where every passing minute without access to caesarean delivery brings with it the reality of delivering a stillborn, or a child with cerebral palsy, and changing a family's lifestyle forever.

In trauma, we talk of the golden hour during which patients must reach the hospital and be attended to. Otherwise, mortality rises. And as experts have argued ad nauseum, trauma mortality supersedes that of HIV, tuberculosis, and malaria combined. 

Posts after posts on social media are awash with medics decrying the above issues. The Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU) has strongly called out the police for harassing its members (read doctors) despite them having the necessary clearance to work round the clock.

Let the fight against the coronavirus pandemic not be more dangerous than the virus itself. 

Research from West Africa has found out that access to emergency caesarean deliveries reduced by up to 40% during the Ebola outbreak. It is easy to take our feet off the pedal and ignore other emergencies to our own detriment. 

In the ongoing environment where Kenyans are flooded with gigabyte upon gigabyte of often alarmist health information, I would not like to do that. 

I have two suggestions on how we can improve on this.

Firstly, I welcome the ministry of Health's suggestion that all elective surgeries be put on hold. In fact, all elective (non-emergency problems) should be put on hold so that we address the emergencies only. That way, we protect our financial and Human resources that are likely to get stretched thin. 

Secondly, it will be wise for the community health volunteers in tandem with the assistant chiefs and village leaders to be put "on call." Seeing as we do not have enough ambulance services to reach every nook and cranny of the society, the community health workers and volunteers should have access to the security agencies and be issued with special "passes" which they can then issue to the boda boda rider or taxi driver to take the injured or sick to hospital. It is easier for the police officers enforcing the curfew to recognize such passes and allow the concerned driver/rider and patient to proceed to hospital and back. These should then be surrendered the next morning as soon as the curfew is lifted. 

Our mantra in medicine is "diseases do not read books." At this hour, I would like to add, 'diseases do not respect curfew.'

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