In 2001 Dr Young Hong Traveled to:
Maua Methodist Hospital
North Meru District, Kenya

Dr David Allbrook Perth, Western Australia

Highlights

The visit of Prof Allbrook was a very valuable opportunity and enabled us to put together a workable proposal for a sustainable community-based palliative care program at Maua.

Dr Dietmar Ziegler, Maua Methodist Hospital, Meru North, Kenya

Despite a high and increasing incidence of cancer, AIDS, TB and other terminal diseases, they have no basic palliative care, no one to give pain medicine, no wound toilet care and no family support.

Dr David Allbrook

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Full Report

International Association for Hospice and Palliative Care: Report on Travelling Fellowship, 2001: Emeritus Professor David Allbrook. Dates: August 25-September 22. Host institution: Maua Methodist Hospital (MMH), North Meru District, Kenya and the Methodist Church of Kenya. Travel: Perth- Nairobi via Air Mauritius, local travel in assigned area by courtesy of host institution. Project Identification: Evaluate needs, existing services and requirements for new palliative services in Meru District, Kenya with particular reference to MMH. Location: (see mud map attached) Meru District is in the Eastern Province of Kenya, mainly on the eastern slopes of Mount Kenya and adjacent hill country at an altitude of around 5000ft. Population is 1.2 million + with a population density of 400/sq.km. The capital is Meru. It is 300km from Nairobi by a good road.Maua (population: 50,000) is the main township in North Meru District. This has a population of above 600,000. The surrounding country is cultivated producing tea and miraa (Khat) as cash crops. There is a substantial amount of forest remaining. Most people depend for their livelihood on subsistence farming.This project was based primarily at Maua Methodist Hospital. There were shorter visits to a rural health centre; Chegoria Presbyterian Hospital (South Meru); Meru District Government Hospital,(Central Meru); Kenya Methodist University; Kenyatta National Hospital, and the Nairobi Hospice. Facility Description: Maua Methodist Hospital (MMH) is a 200 bed facility with an adequate operating theatre suite, excellent burns unit, casualty and out patient department and medical, surgical, paediatric and obstetric / gynaecological wards. There is an excellent Community Health program (MCH, Schools, TB- DOTS), with AIDS Prevention and AIDS Orphans programs all serving North Meru sub- District. There is a specialist facility for disabled children assessment and care in co-operation with the Kenya Education Department. The School of Nursing is a major department for basic nurse training.Staffing is by Kenyan medical and nursing, therapy and pharmaceutical staff. Overseas workers serve on medical, teaching and support staff. MMH is heavily dependent on overseas capital and practical service aid supported by Methodist churches in UK, USA and Germany.

Patients are charged for services but the hospital carries a major debt burden. The local church though very poor takes some responsibility within its means to support the hospital services offered..

At present there is no palliative care department or training facility.

Problem Identification: North Meru District has a population in excess of 600,000. Poverty is widespread among the subsistence farmers of Meru. Amongst the very poor dying at home (an unknown number) there will be hunger in the patient and often in the family. They have no basic palliative care, no one to give pain medicine, no wound toilet care and no family support. Cultural reasons dictate that at the cost of much suffering patients are often rushed to hospital when death seems near. This causes unsupportable debts and a death in alien surroundings without family support. (Grant, personal communication). Disease pattern: At MMH (North Meru) cancer patients always present at an advanced stage. Where indicated palliative surgery is the norm and (what I have seen in this short visit) is done well. Chemotherapy/ radiotherapy is not available in Meru District. It is occasionally recommended when it is offered in Nairobi. It is beyond the means of most patients.There is no known 5 year remission rate of cancer among patients diagnosed. No cancer registry is kept. Data on confirmed histopathology is unavailable. Anecdotally cancer is said to be increasing in parallel with the AIDS pandemic.In the year 2000: - total inpatients=7600.Among 1735 adult medical inpatients there was (an estimated ) Stage 3 AIDS rate of 15% Blood donors HIV+ve rate= 10%. There is a yearly incremental rise from 1% since blood donor testing began 10 years ago. At Chegoria Hospital (South Meru) HIV/AIDS, malaria, cancer and cardiac problems account for the majority of deaths.In the year 2000:- 286 cancer cases were diagnosed, (gastric 27, breast 19, oesophagus 16, primary hepatoma 17) Deaths attributable to HIV/AIDS were 20.36% of adult deaths. 50% of bed occupancy in this hospital is said to be HIV/AIDS related.A qualitative study by Chegoria Hospital and Edinburgh University Dept of Family Health cited by Dr Elizabeth Grant et al indicates that in the hospital’s South Meru area about 70 patients suffer terminal end stage illness at home without proper palliative care. In Meru District Hospital (Central Meru) 120 new cancer cases are recorded annually of whom 50-80% are said to die within the year. The HIV rate is 19.6%.There are no reliable data on the numbers of patients dying at home with HIV/AIDS in the District. Conclusion: the probability is that the best available figures from Chegoria Hospital reflect the pattern of infectious and malignant disease in the entire Meru District.Despite a high and increasing incidence of cancer, AIDS, TB and other terminal diseases present in this urban and rural community palliative care services are absent apart from the small initiative at Chegoria. Project Procedure: I was based at MMH. I utilised 4 days travel time in Nairobi to attend to administration of future palliative care projected programs and visit Nairobi Hospice twice. At MMH I did ward rounds for one week re-familiarising myself with African medicine and teaching clinical methodology and palliative care to staff and visiting German medical students. I gave two lectures to full meetings of the clinical and nursing staff at MMH. I discussed plans with Dr John Harbottle a visiting doctor and past Medical Director of MMH (who is reporting to Hospice Kenya a British based charity supporting Nairobi Hospice). With Dr Dietmar Ziegler the Medical Director I had several long discussions about practical needs involved in a community based palliative care service for North Meru based at MMH. We together developed project proposals. (Attached).I visited Chogoria Hospital for two days and discussed future collaborative palliative plans for the District with Dr Grant and her medical colleagues.I had two discussions with staff at Nairobi Hospice (Drs Ali and the CEO Mrs Sirengo) about its clinical activities and the involvement of Oxford Brookes University in their joint palliative care educational program. This is a certificate course which emphasises socio-cultural aspects of palliative care, and is attended annually by an average of 10 nurses from different parts of East Africa. It is expensive.At Meru District Hospital I visited the allocated room for the proposed Meru Hospice currently in the initial stages of planning. I discussed the proposal with the Hospital Matron and its initiator Dr Bactrim Lillengo who sit on the Development Committee composed of representatives from the 3 hospitals in Meru District plus Nairobi Hospice. I read the minutes of this meeting, held monthly over the last 7 months. It is about to be registered as a charity.I spent time with and assisted a visiting American team at a one-off clinic in a rural dispensary who were doing HIV tests on random local populations. 2+ve out of 30 tested. I had meetings with the Board of MMH and other leaders of the Maua community and significant church leaders. All of these people needed to be made aware of the potential for the relief of suffering offered by a properly conceived community based palliative care service in their district. I did my best and got an enthusiastic response to the idea of offering simple care training by visiting nurses to the people of five selected parishes.

Personal Outcomes: 

1. I informed Maua (MMH) and Chegoria Hospital and Nairobi Hospice administrations that I am a Travelling Fellow of IAPC and encouraged each of these institutions to join. 2. I now have an up to date appreciation of the present situation in regard to the needs for networking and cooperation between institutions to provide appropriate palliative care services in this part of Kenya to meet the accelerating problems of cancer and HIV/AIDS. 3. I have a deepened appreciation of the depths of suffering in the circumstances of these diseases in rural Africa and have seen it at first hand. 4. I recognise that when applied in this situation the principles of palliative care relieve a great deal of suffering (Have these sometimes been forgotten in our sophisticated practice of palliative medicine in Australia?). 5. I observe that the list of additional effective medications needed is short and inexpensive.I found the old ignorance and prejudice against the use of opioids still entrenched in nursing staff and regulations still in place which effectively barred its use. I was able to suggest ways to overcome this barrier. It is now available in MMH and Chegoria Hospital. 6. I noted the absence of basic palliative care nursing applications to patient needs in all three of the hospitals visited, reminding me of the situations I used to see as a dresser or clerk (old English terms!!) when I was a medical student in London in 1945. I was able to give a few practical hints on patient care during visiting ward rounds. 7. Education of the family is a big unmet need. So is education about the medical facts of cancer and HIV/AIDS in the community where there is widespread ignorance and prejudice. Education of the family and patient about the process of dying and education of care-givers about cultural and spiritual aspects of illness and death in their society should all form a part of the training and education of new palliative teams here.

8. I plan to return to MMH in February next year for three months to implement the projects listed.

Administrative outcomes: 

1. A plan to extend Dr Grant’s research into "patient and family preferences on places of care and place of death" into North Meru based on MMH. This will be a cooperative research into possible cultural differences between two Meru sub-tribes. The newly recruited team will continue to work if funding can be found for an ongoing community and hospital based palliative care program at MMH.

2.Construction of applications for support for my return next year to help initiate this service and cooperate with the Meru Hospice project and Chegoria service.

3. I have been asked to give a two day crash course in palliative care to health professionals in Meru at Kenya Methodist University.

4. Co-operation ongoing with Hospice Kenya (a UK based private charity) and the Methodist Church of Kenya (which has offered to be my sponsoring body).

5 Collect and transfer gifted relevant pharmaceutical products and raise AUS $18,000, half the purchase price of a Suzuki 4WD to be used for the community palliative care program at MMH.

6 Application for personal support of return 3months visit in Feb.2002 to implement these programs, total of. Aus$3500 and separate budget for the community palliative care /hospital department at MMH.

I thank IACP for supporting this personal volunteer project, coupled with the hope that additional personal support may be offered to help me initiate the program outlined next year.

David Allbrook, MB, BS (London), PhD(London), FAChPM (Hon), Emeritus Professor, University of Western Australia.
Address: The Old Forge, Union Road, Carmel, WA 6076 Western Australia
Phone in Australia 08 9293 5220
FAX 08 92935001
E-mail: dallbrok@cygnus.uwa.edu.au

Submitted by: Dr David Allbrook