‘Here!’ Nancy gives me a nudge. ‘We are here!’
We squeeze ourselves, like toothpaste, out of the matatu collective minibus which halts for a few precious seconds before roaring up the road again.
The greyness of Nairobi has given way to a landscape of green and rolling hills. This is where Nancy worked for eight years until 1994.
We pass through the gates of Tigoni Community Hospital. ‘I used to bring student nurses here to show them how a rural hospital functioned,’ Nancy explains.
Nancy used to bring student nurses to this hospital, in the days when Kenya had a health system to be proud of. Photo: Vanessa Baird Set on a hillside, with white buildings, trees and flowering shrubs, it has a calm and pleasant atmosphere.
We bump into a couple of Nancy’s relatives from her husband’s side of the family – a brother and sister. They are here to visit their brother, who was admitted three days ago. They invite us to come in and see him. We enter a women’s ward of about a dozen patients, which leads directly into the men’s ward with slightly fewer. ‘Basic’ is the kindest way to describe the conditions. Sheets are sparse and dirty, blankets thin, old and soiled. No modern equipment to speak of. Most of the people look very ill indeed. Thin, they clutch blankets to keep warm.
Nancy’s relative is in a bad way, barely able to acknowledge his visitors. Though he doesn’t really need to, his brother explains: ‘AIDS. Acute phase.’ The sick man is 43 years old. A daughter of his, who came to see him, ran away when she saw the state he was in. In spite of his condition – or because of it? – the hospital is discharging him today.
‘We will have to carry him home,’ his brother tells me. The sick man will go to live with his mother, who is elderly, unwell and poor. This is called ‘home care’. The relatives are still hoping that they might be able to get him into another hospital where he could get some medication. It’s all a bit vague.
Anti-retroviral drugs (ARVs) – which help to reduce symptoms and extend the lives of people with HIV – are still comparatively expensive and are only available to one in five of the Kenyans who need them.1
The man’s brother asks me about treatment for HIV in my country. This brings us both slap up against some unavoidable truths. It’s not just the scale of the epidemic in sub-Saharan Africa, but the availability of treatment. Whether you can live with HIV or not really does depend on the geography of wealth and poverty.
In Britain, where ARVs are widely available and nutrition, health and living standards are so much higher, 500 people died from HIV-related causes in 2003. That’s 1 in 64 of the 32,000 people infected. Australia has a similar ratio, with 200 deaths out of 14,000 with HIV. In Kenya, 140,000 people died of HIV-related causes in 2003 – that’s 1 in 10 of the 1.4 million people infected.2
All the patients in these two wards have HIV-related conditions. The fact that there are more women than men reflects the national reality. Women in Kenya are almost twice as likely to be infected – nine per cent of the population compared with five per cent of men. Poverty and the position of women in society, and within heterosexual relationships, make it harder for women to insist on condom use and may also push abandoned women into occasional sex work to provide for their families. Nancy knows women who have become HIV-positive in this way.
Nancy and I try to find someone in a position of responsibility who can talk to us, but no-one will. As we go out of the hospital gates Nancy is subdued. I ask her if she is shocked by the state of the wards.
‘I have seen it happen gradually,’ she says. ‘When I first qualified as a nurse in 1978 we had a really good health service in this country. The standard of care was good. But it deteriorated throughout the Moi period and now it is very poor. You can see that for yourself. Before, people were treated as people. Now they are treated like rejects.’
The Moi regime can be blamed for much. But there are other powerful forces at work too. During the two decades after independence African countries saw major health improvements. In Kenya, for example, child mortality was reduced by almost 50 per cent between 1963 and 1983. Across sub-Saharan Africa average life expectancy increased from 44 years to 50.3
But in the 1980s and 1990s – when commodity prices collapsed and debt soared – African governments had to cede control over their economic decision-making in order to qualify for World Bank and IMF loans. Conditions attached to these loans undid much of the progress in public health. Food subsidies were scrapped, health budgets slashed and services privatized. ‘User fees’ were introduced for health services that were previously free to patients. The capacity of African governments to cope with the growing health crisis was weakened. The life expectancy of Africans has fallen by 15 years.3
If Tigoni is an example of the state of things in a rural hospital, I wonder what it’s like for the massive Kenyatta National Hospital (KNH) in Nairobi. Nancy worked here too, between 1974 and 1986. It’s where she did her training and she remembers it as ‘a very good hospital’.
At first glance KNH resembles a large British hospital. Even the typography of the signs and the yellow painted doors is familiar. But I doubt many British hospitals experience quite the Himalayan challenges that confront staff at Nairobi’s busiest hospital every day.
I have heard, from nurses working here, that patients often have to share beds – two or three to a bed, on the floor, along corridors, wherever there is a bit of space.
The hospital’s Press Relations Officer, Hannah Jakuo, is candid. ‘We never turn patients away,’ she explains. ‘And they come here from all over the country. This was never intended to be a general hospital. It’s meant to be a specialist referral and teaching hospital, but we have to deal with everything that comes to us: TB, malaria, accidents, everything.’
The Government is now able to get hold of IMF funds after a four-year suspension during the Moi era. True to form, the IMF is demanding major cuts in public spending. The Health Ministry is slashing funding to KNH, putting it under pressure to privatize more wards and extract fees from all hospital patients.
The impact of fees on infant and maternal mortality is high. To avoid them, many women opt for risky home-births. ‘Others try to save money by leaving going into hospital as late as possible,’ says Nancy. But the consequences can be fatal. One of Nancy’s nieces died in childbirth because she delayed going to hospital for financial reasons.
Kenya’s maternal mortality rate is high: 414 in every 100,000. The infant mortality figure is worse still: 114 for every 1,000 live births, compared with just 5 in Britain. Kenyan Health Minister Charity Ngilu has warned that the country has no hope of meeting its Millennium Development Goals for reducing child and maternal mortality.4
And, of course, there is that other problem: ‘There is a lot of brain-drain to Britain and America,’ says Hannah Jakuo. ‘We [at KNH] are at least 1,000 staff short. The WHO recommends a nurse/patient ratio of 1:6. Here we have a ratio of 1:30.’
There are around 12,600 nurses currently employed in Kenya – the Association of Nurses says the country needs at least another 7,000.
At KNH some 60 per cent of the patients in the general medical wards are there with HIV-related conditions. Thinking of Nancy’s relative in Tigoni I ask whether these patients get ARVs. ‘No,’ Hannah replies. ‘Not everyone can get them because of the high demand and we don’t have enough to go around.’
More international funding would certainly help. But ARV therapy requires trained health workers. And there’s the rub. For funding does not necessarily translate into jobs. Take the case of Uganda, which recently had to refuse some international AIDS funding because it would take the country over its IMF-imposed cap on public sector employment.
But Dr Francis Kimani, a spokesperson from the Kenyan Ministry of Health, confirms that there are around 5,000 new unemployed nurses in the country.
‘It’s a disaster,’ he says. ‘All the good brains are leaving because they are promised better salaries and working conditions in the developed world. And we can’t employ new ones because of an employment embargo set by the IMF.’5
The plot thickens when a spokesperson from the World Bank in Nairobi says: ‘The Bank has not put any embargo on recruitment of nurses or civil servants in general. The overall level of wages and salaries bill is an issue though, and the IMF has been discussing with the Government how the wage bill could be contained.’5
While ‘brain-drain’ is an easy explanation for Kenya’s ailing health system, it is only part of a far more complex picture – one which includes the low priority given to health, both nationally and internationally.
I’m a bit worried about our next visit – to the Kenyan Nurses Union. The Union has been quite vocal in its criticism of countries that ‘poach’ African nurses. Nurses like Nancy who leave the country – sometimes without notice, for fear of attempts to stop them – are adding pressure on those left behind. The issue is delicate.
In spite of his condition – or because of it? – he is being discharged today
Honorary Secretary of the Union, Evelyn Mutio, tells us: ‘We can’t stop nurses going to greener pastures. It’s like a mother who tries to keep her daughters in by locking up the doors and windows. It’s no good. They will find a way out.’ She should know – she herself worked abroad for several years.
Mutio wants to see international recruitment taken out of the control of private agents and regulated by a responsible body. ‘We want equality for all nurses,’ she says. ‘The rich countries are using international nurses as cheap labour, and an international body needs to establish some kind of standard.’ She believes the International Council of Nurses (ICN) could play this role.
There are many stories of nurses being cheated and exploited. Often the authorities blame agents, without actually doing anything to control them. Some nurses have been bound into contracts which do not allow them to return home within five years. Their passports are taken away from them. Others have gone abroad as fully qualified and experienced nurses only to find themselves employed as poorly paid auxiliaries.
‘We get some of our nurses calling us from abroad and asking for help,’ says Mutio. ‘But what can we do at that stage? What we now say to nurses is: “Tell us where and why you are going. Are you going to an accountable place? Can you come back if you want to?”’
The major challenge is how to motivate nurses to work in Africa. Apart from the obvious need for more pay, Mutio thinks the retirement age should be raised from 55 to 60 to enable older nurses to carry on earning. Those who have worked abroad should be actively invited back into the health system. And she sees no reason why some nurses from richer countries shouldn’t do a stint in Africa to expand their knowledge of tropical diseases.
For Kenya to hold on to its nurses – and recruit new ones – will require something else, too. Various conversations I have with nurses indicate that morale is very low.
One explained: ‘You may have lots of good practice in your head – but if you don’t have the resources, what can you do? Nurses are most happy when they take care of a very sick patient and send them home healthy. AIDS has changed all that.’
The ‘push’ factors propelling Kenyan nurses towards the ‘greener pastures’ in the West are many and great.
But we are about to see someone who is longing to join her country’s health system. Nancy’s sister-in-law, Lois, lives on a farm near Ngong in Rift Valley province with her husband and their grandchildren. Nancy has heard that the eldest granddaughter, also called Lois, needs to talk to her. We make our way up a hill through fields of maize, tomatoes, kale, bananas; grandmother Lois gives a whoop of delight when she spots Nancy.
As we sit inside the house two small boys, aged about six and four, appear in the yard and inspect us through the doorway. The older boy points out the white woman to the younger, who stares – aghast. I wave to him and his mouth falls cavernously open to let out the most desperate wail.
I can’t blame him. Bad enough to have a ghost sitting in your living room. But for that ghost then to proceed to give you a twinkly wave is beyond endurance. The poor child remains in hiding for the rest of our visit, to the cruel delight of his elder siblings.
We peel cabbages and potatoes and 19-year-old Lois cooks them up for us. She is gracious, good-natured – but frustrated. She can’t seem to get an ID card she needs for a nurse training course. There is a minor discrepancy between the date on her birth certificate and that on her school leaving certificate. Might this be causing problems? Nancy thinks it more likely that an official either can’t be bothered or is waiting for a bribe.
‘You see, this is the way they keep people from achieving things. They want poor people to stay poor,’ she says. ‘People like us are timid; and they want us to be timid.’
Lois is motivated but lacks confidence. Her grandmother is supportive but illiterate. Age and experience have made Nancy assertive. What will Lois’s path be? Will the quiet determination that enables her to say ‘I will press on’ be enough to carry her through? Or will she be blown off-course by poverty, corruption and prejudice?
The girl’s grandmother tells Nancy: ‘You are our saviour.’
Nancy looks uncomfortable. It’s not clear what she can do to help. She gives Lois 1,000 shillings ($14) to register with the Medical Training Centre and tells her not to wait until she has the ID. It seems to be the right advice – confirmed a few days later. Nancy’s son Joel agrees to help get the paperwork sorted.
Maybe Nancy, whose surprise visit got things moving again, proved to be a saviour after all.
- 1 Kenyan Ministry of Health
- 2 UNAIDS, 2004 ‘Report on the Global AIDS Epidemic’.
- 3 Ann-Louise Colgan, ‘Hazardous to Health: the World Bank and IMF in Africa’, Africa Action Position Paper, 2002.
- 4 UN Millennium Project Global Report, 2005.
- 5 Additional reporting by Josefine Volqvartz.