Doctors News, Volume 9 / 2009 – 1 · PDF fileOur Doctor Profile in this issue is renowned psychiatrist, Dr Frank Njenga. He talks about his passion for psychiatry and his efforts

Doctors News, Volume 9 / 2009 – 1 –

– 2 – Doctors News, Volume 9 / 2009


F r o m t h e C o n t e n t s

Cover Picture: Anthony Njoroge

B u s i n e s sBoost your career with an MBA 9 by Carole Kimutai

O p i n i o n Celebrating Doctors’ Day by Dr J A Aluoch 10

Death in hospital wards by Dr Misaki Wayengera 11 M a i n F e a t u r e Disaster ManagementHow prepared are we? by Patricia Muigai 12

Medical disaster preparedness in Kenya; status and the way forwardby Dr J N Micheni and Dr P K Wanyoike 14

The Pakistan Experience by Dr Martin Awori 15

D i s e a s e P i c t o r i a l Toxic Epidermal Necrolysis and Steven Johnsons Syndrome by Dr Anne Wairimu Imalingat 18

D o c t o r P r o f i l e Dr Frank Njenga Living his dream by Patricia Muigai 20

F e a t u r e HaemophiliaA lifelong doctor-patient partnership by Professor Walter Mwanda 26

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On January 18 2009, 29 people died and 24 others were seriously injured when a truck collided head on with a bus on Mombasa Road. Ten days later 29 people perished in the Nakumatt Downtown Supermarket fire. In March 2009, 130 people perished in

Sanchangwan, in a fuel tanker tragedy. Barely four months later another 45 were seriously burnt in Kapokyek, Kericho District while siphoning fuel from a tanker. that had crashed. In a bizarre massacre in April 2009, 29 people were hacked to death by a terror gang in Mathira, Nyeri District.

How prepared are we as a country and as the medical sector to manage both natural and man-made disasters? Our main feature in this ninth issue of Doctors News EA is on Disaster Management. Issue Editor, Mr Abbas Gullet, Secretary General of the Kenya Red Cross Society (KRCS), begins with an outline of disaster management, gaps and solutions in Kenya and disaster preparedness manager KRCS, Mr Davis Okoko discusses how prepared Kenya is. Dr Martin Awori, writes about his Pakistan disaster management experience and finally Kenyatta National Hospital’s Dr J Micheni and P Wanyoike focus on the way forward in disaster management in Kenya.

Our Doctor Profile in this issue is renowned psychiatrist, Dr Frank Njenga. He talks about his passion for psychiatry and his efforts to reduce the stigma that accompanies psychiatric patients. Professor Walter Mwanda writes an in-depth feature on the management of hemophilia, a lifelong malady fraught with perhaps worse complications than the disease itself, while Dr Anne Wairimu Imalingat, unravels the little known life threatening dermatological emergencies, toxic epidermal necrolysis and steven-johnsons syndrome.

In our regular opinion and business columns, Dr J A Aluoch educates us about Doctors’ Day, while Ugandan Dr Misaki Wayengera, questions whether there is a need for a desensitization programme for patients who shared the same ward with patients who have died. Carole Kimutai, advises doctors on how they can boost their career with an MBA. In our industry news we have a unique call to doctors by US ambassador, Mr Michael Rannenberger, to participate in the political debate to ensure true reform in Kenya is timely, given doctors apathy in this regard.

We would like to remind our readers and advertisers that Doctors News EA is a subscription magazine for doctors only published by doctors. It is the only magazine of its kind and is distributed to registered physicians across East Africa. As always, we invite you to share your wisdom, products and services with other doctors in the various fora afforded by Doctors News EA.Enjoy the magazine.

Dr Robert Mathenge

M e d i c a l E d i t o r N o t e

Doctors News East AfricaMedical Editor Dr Robert Mathenge [email protected]

Issue Editor Mr Abbas Gullet

Editorial Advisory Board Dr J A Alouch Dr P H Rees Dr J B O Okanga Prof Zipporah Ngumi Dr Stephen Muhudhia Prof John Atinga Dr Willy Mutunga Dr Githinji Gitahi Carole Kimutai Joe Muchekehu Sam Madoka

Editor Sharon Murekio [email protected]

Sub Editor Patricia Muigai [email protected]

Contributors Carole Kimutai, Dr J A Aluoch, Prof Walter Mwanda, Dr J Micheni, Dr P K Wanyoike Dr A W Imalingat and Dr Misaki Wayengera

Business Development Manager Clement Agot [email protected]

Business Executive David Wanga [email protected]

Subscriptions and Circulation Bernix Oduor and Joseph Maina [email protected]

Publisher Sterling Media Limited Kugeria Maisonettes House 9, Ralph Bunche Road, P. O. Box. 2665-00200, Nairobi, Kenya. Tel: +254-20-271-2121 Cell: +254-722-698211 Email: [email protected]

Disclaimer: Although every precaution has been taken to ensure accuracy of published materials Doctors News East Africa cannot be held responsible for opinions expressed or facts supplied by its authors. Printed in Kenya. Copyright, Sterling Media Limited. All rights reserved. Doctors News EA is published by doctors for doctors six times a year.


I s s u e E d i t o r N o t e

Disasters in Kenya Gaps and possible solutions

A disaster is a catastrophic or traumatic situation or occurrence in which the day-to-day patterns of life are suddenly

disrupted, often causing widespread human, material or environmental losses or damage exceeding the ability of the affected community to cope with. Due to limited resources, affected populations normally seek external support to tackle disasters.

Disaster management involves adequate preparedness of various facilities and systems required for response operations such as emergency or standby technical, material and financial preparedness, communications and a warning system. Provision of early warning of an impending or probable disaster reduces the severity of the impact. Preparedness also includes surveying and assessing the needs, emergency relief arrangements, training and maintenance of disaster preparedness levels through exercises and tests, functional and readiness checks, and post disaster review. If unchecked, preparedness tends to fade away.

Disaster preparedness, response and management operations are inadequate in Kenya. Nationwide disasters pose a major challenge to both the Government and the public. Leaders have failed the public by not putting in place good policies that will protect them from disasters and/or their impact. Man-made disasters such as collapse of buildings, fire outbreaks and resource-based conflicts are preventable. However, due to poor planning, corruption and negligence, they have become common occurrences in Kenya. No significant organisation in the country addresses disasters proactively.

When a disaster strikes, recovery work is made easier if such efforts are supplemented with proactive activities such as prevention and mitigation. This is currently lacking in Kenya. Kenya Red Cross has responded to complex emergencies. It has years of investment in training of staff and volunteers, stockpiling and logistical support, disaster preparedness, disaster response and a vibrant team of staff and volunteers. The Society’s preparedness translates into action whenever disaster strikes.

Mr Abbas GulletSecretary General, Kenya Red Cross Society

About the issue editorMr Abbas Gullet has been the Secretary General of the Kenya Red Cross Society (KRCS) since 2005. KRCS is the largest humanitarian organisation in Kenya established in 1965. Mr. Gullet joined the Kenya Red Cross as a National First Aid Officer in 1985 to 1988. He then worked as the Society’s National Youth Officer before being deployed as the Branch Development Officer. In 1991, Mr. Gullet was elevated to the position of Youth Officer, Youth Department International Federation of Red Cross/Red Crescent Societies (IFRC) in Geneva for six months. He wrote two manuals, on Red Cross and Red Crescent Youth Leadership and Youth Environment in collaboration with United Nations Environment Programme (UNEP). He also worked as Relief Coordinator with IFRC in Malawi between 1992 and 1993. Between April and June 1993, Mr. Gullet was the Acting Head of Delegation for IFRC, Malawi. He oversaw the Malawi drought and Malawi Cholera/ Bloody diarrhoea operations. Between June-September 1993, as the Head of Sub-delegation, IFRC in Malawi, Mr. Gullet was responsible for Mozambican Refugees Programme of one million people. Mr Gullet has worked as IFRC’s Head of Delegation in Uganda, Head of Youth Department, Head of sub-delegation in Niagara, Tanzania, Deputy Head of Regional Delegation for East Africa, Nairobi in Kenya, Head of Delegation Sudan, Head of Delegation, Pacific Region, Secretary General and Director of Operations IFRC, Treasurer of KRCS – elected by the Council of Delegation.Mr. Gullet is a holder of a Post Graduate Diploma (MBA) in Practising Management (INSEAD 1997) from Lancaster University, McGill University, Hitotubashi University, and Bangalore School of Management. He was recognized as the UN Person of the Year in 2007. He holds an Order of the Golden Warrior from the Kenya Government.


I n d u s t r y P i c t o r i a l

Jemimah Kimeu (left), of the Aga Khan University Hospital, ties a blue ribbon on Kunal Parbat of Wheels of Africa. Kimeu flagged off Wheels of Africa team who rode their bicycles from the AKU outreach clinic at Prestige Plaza, Ngong Road, to the main University Hospital where a colon cancer open day was held

Dr Martin Krestanpol of QIAGEN conducts a Diagene HPV test training at the Kenya Medical Training College in Nairobi. The Diagene HPV test is now available in Kenya

Participants listen keenly to a presentation by Dr F A Okoth on the epidemiology of the Hepatitis virus in Kenya. This was during a Hepatitis mini-symposium hosted by Hoffmann La Roche Kenya Ltd in Nairobi in May

From right, Autism Society of Kenya (ASK) Founder, Felicity Ngungu, Citizen TV’s Julie Gichuru and Karen Kirubi of Telkom Kenya during the ASK Annual Fundraising Dinner held in Nairobi

Dr Omondi Ogutu and Dr N Thagana share a light moment during a dinner held to recognise senior doctors by The Nairobi Hospital. US Ambassador to Kenya, Mr Michael E Ranneberger was the chief guest

Hon Dr Mohammed Abdi Kuti Minister for Livestock and Development is welcomed by (L) Mr Gordon Bell, Chairman Mr Alec Davis and Mrs Andy Russell Trustees during the first anniversary and official opening of Gertrude’s Pangani Clinic


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I n d u s t r y N e w s

True reform in Kenya: “Get involved” doctors told

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TriFour Health (Pty) of South Africa in partnership with Orca Investments (East Africa) Ltd of Kenya have launched TriFour Healthcare (EA) Ltd. The company is providing information technology

(IT) based health management system solutions that improve patient care and cash flow in hospitals and clinics in the region. The TriFour Healthcare systems use new technologies such as short message service (sms), email, document scanning, bar codes and photography. Bar coding is used in patient admission and tracking and drug and medical consumables tracking through a hospital or clinic. The Patient Management System Solutions optimise and improve patient management and care while ensuring strict management control. The company’s systems embrace new technologies such as short message service (sms), email, document scanning, bar codes and photography.Other solutions include applications for integrated case management in hospitals and control of pharmacy stocks and point of sale systems.Finally, the company provides unique solutions in Electronic Patient Records (EPR) and Electronic Data Interchange (EDI) account submissions. Accounts for patients are made available immediately on discharge providing real time billing is done. The company will develop, install, train staff, and maintain systems for hospitals, clinics, pathology laboratories, radiology departments and multi disciplinary medical clusters in the private and public sector.TriFour Health (Pty) has installed its health management systems in 35 hospitals across Africa, including South Africa, Ghana, Tanzania, Zimbabwe, Namibia and Malawi.The company directors are Johann Odendaal of TriFour Health (Pty) and John Sawers of Orca Investments (EA) Ltd. The company will provide healthcare solutions throughout East Africa.

TriFour Healthcare launches in East Africa

The US ambassador to Kenya Mr Michael E Ranneberger has called on doctors and other professionals to show interest and actively participate in politics to ensure true reform in

Kenya. He said that the more those outside the political class get involved in politics the more the chances of delivery of true and sustainable reform. The ambassador indicated that the major level of US-Kenya interaction is not governmental but non-governmental; between NGOs, communities and individuals. He said this interaction is deep rooted and mutually beneficial, going back many years.

Ambassador Rannenberger was speaking during a dinner held for the Nairobi Hospital admitting doctors. The dinner was held to recognise the Nairobi Hospital doctors for supporting the hospital, enabling it to achieve the success it is today. Out of the approximately 430 doctors with admission rights, about 300 attended, making the occasion an outstanding success. Doctors who had worked for the hospital for 30 years and over were awarded.

The Nairobi Hospital Chief Executive Officer Dr Cleopa Mailu lauded the doctors for the success the hospital is enjoying today. He said that this success was as a result of their goodwill and encouraged them to continue supporting the hospital.

The US ambassador to Kenya Mr Michael E

Ranneberger


The insecticide, Deltamethrin, is incorporated in the fibre during the yarn-making process and has the ability to migrate to the surface of the yarn through a controlled release system making Netprotect® an efficient mosquito killing net. Most of the Deltamethrin is located inside the yarn, providing complete protection against external exposure such as washing.

Users can wash Netprotect® up to 35 times depending on the conditions, and still receive full protection against disease vectors. Netprotect® is the only LLIN net on the market, which dries in the sun after a wash. The lightweight net has a high strength. Life expectancy is five years; double that of many others in the market. Several field studies on Netprotect® have been conducted in Indonesia, West Africa, Kenya, India and Tanzania. The launch in Kenya marks yet another milestone towards the fight against malaria as advocated by the WHO Roll Back Malaria Initiative. Netprotect was launched in 2005.

W h a t ‘ s N e w

Achelis launches long lasting insecticidal net

Bestnet Europe and local agent Achelis (K) Ltd have launched a new long lasting insecticidal net, NETPROTECT®, in the

Kenyan market. Kenya requires at least 10 million mosquito nets annually. Often, the challenge is to get enough manufacturers to supply these nets.

The launch of Netprotect is therefore a major contribution to the malaria control programme, which aims to meet the annual Long Lasting Insecticidal Impregnated nets (LLIN) requirement.Netprotect® is washable and resistant to sun light exposure. It is produced in standard 136 and 200 meshes (holes/inch²) and is available in all colours. It has been extensively tested and passed the WHO Pesticide Evaluation Scheme (WHOPES l and WHOPES ll).

Dr Odicho Gesami, Assistant Minister for Public Health and Sanitation and Mr Gideon Mworia, Director Achelis (K) Ltd during the launch

Doctors News East Africa is a subscription based magazine published by doctors for doctors. It is distributed and enjoys wide readership by physicians across the East

African region.

Are you:Launching new products and services?

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Email: [email protected]


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B u s i n e s s

Boost your career with an MBA

A change is as good as a rest. If you are in that stage in your life where you need to do something different and probably run your own business, taking a master’s degree in business administration

(MBA) is guaranteed to broaden your view of the business world. The current economic scenario has forced people to develop varied ways to survive. Companies are downsizing, governments cutting costs and donors reducing funding. With the sky rocketing prices, basic commodities have become dear forcing many of us to tighten our belts. The economic sector is also reporting slow business.

MBAs are popular amongst professionals in finance, marketing, management and business development. In the banking sector for example, an MBA is a basic requirement. Those who do not have the qualification have joined the numerous business schools locally and abroad that are offering the programme. Medical professionals are encouraged to pursue this degree that is opening doors to endless career and business opportunities. Graduates can get senior management level appointments, start their own businesses or become consultants for local and international organizations. There is more emphasis around the world on quality health care and management. Governments are investing money in research and in prevention of diseases and MBAs are coming in handy. According to an article titled “Healthcare MBA: One fast track in a slow economy,” the global focus on health has created a whole new set of roles in health care for MBAs, especially for those with some clinical understanding. “Those who have some knowledge about the distinct features of the health care system, such as its financing and the unique roles that physicians play, are in an even better position to win the leadership positions in major health care organizations,” states the article.

Using your MBAAn MBA is a postgraduate qualification that covers areas such as finance, personnel, and resource management including a wider business environment and skills such as information technology use. The course is recommended for professionals who have some managerial experience or desire a managerial role.

In Kenya, private investors are setting up medical and health institutions, which need to be managed by professionals. With the biting financial crunch, these investors will look for professionals who can manage rising costs and make money. According to MBA Focus, both pharmaceutical firms and health care providers, including hospitals, are hiring an in-creasing number of MBA graduates. If you are a paediatrician in charge of a children’s wing in a hospital, knowledge on human resource management will teach you how to under-stand your staff better, motivate, punish and reward them.

You could be a consultant wondering how to market your services on a string budget. An MBA will teach you a thing or two about online marketing and using client management resource systems to manage your clients professionally. If you are a clinician and want to change to something differ-ent, you can go into marketing, insurance, and consulting.There are specific MBAs for medical professionals. Universi-ties in Britain, Canada and America have MBAs in health and medicine. The courses offer clinicians a diverse range of ca-reers ranging from academic medical research to the design, management and evaluation of healthcare delivery systems. Various local universities are also currently in the processes of developing health based MBA programmes. If you are looking for further career opportunities, learn something new or know how to make money, an MBA is a good option.

By Carole Kimutai


who have chosen this vocation, to serve their fellowmen understand the tremendous responsibility it entails. There is no greater reward in our profession than the knowledge that God has entrusted us with the physical care of His people. The Almighty has reserved for Himself the power to create life, but He assigned to a few of us the responsibility of keeping in good repair the bodies in which this life is sustained. Accordingly, reverence for human life and individual dignity is both the hallmark of a good physician and the key to truly beneficial advances in medicine.

It is indeed true that physicians value the gratitude of their patients and this makes Doctors’ Day relevant and significant in the larger context of health care. Doctors’ Day varies in different countries and in Kenya, we need to designate a special day convenient to celebrate Doctors’ Day. A day when the community would recognise the irreplaceable role doctors plays in their lives. It is indeed important that doctors and patient are aware of the existence of this day and at the same time of its relevance and significance in the larger context of health care in our country.

Perhaps in future, doctors in Kenya in the “harambee spirit” would mark Doctors’ Day with some type of community health activities to further good public relations of the medical profession, for example organizing awareness programs for various pressing health problems.Doctors’ Day might provide the opportunity to negate to some extent unfavourable demoralizing, vexatious pronouncements of minority of patients often grossly exaggerated by the media and some other agency. Towards this objective, it is worthwhile to awaken the silent majority of patients who have a prayer in their hearts for doctors and do not speak out to let the world know.

O p i n i o n

By Dr J A Aluoch F.R.C.P, EBS

Celebrating Doctors’ Day

Recently the Nairobi Hospital hosted a sumptuous breakfast for their doctors in celebration of Doctors’ Day. A few doctors were at hand to learn about the significance of the day. However,

many did not show up and even more were not aware of the occasion. Indeed many physicians do not even know of the existence of Doctors’ Day.

Doctors’ Day was conceived by Eudora Brown Almond of Georgia USA. Eudora Brown developed an abiding respect for doctors, based on the kindness of the Brown family physician, when she was a child. After her marriage to Charles B Almond, MD, her appreciation for the humanitarian work of physicians increased. She chose March 30 to celebrate this day, because she knew that was the day Crawford W Long performed the first anaesthetic in nearby Jefferson, Georgia in 1842. The first Doctors’ Day was celebrated in Barrow County, on March 30, 1933. The day was commemorated by a resolution by the Barrow County Medical Society, placing flowers on Crawford W Long’s grave, and a formal dinner for the county’s doctors at the home of the President of the Barrow County Medical Society. The celebration grew in popularity and, in 1985, the USA House of Representatives passed a resolution recognizing March 30 as Doctors’ Day. In 1990, the U.S Congress passed a Bill designating March 30 as Doctors’ Day and President George Bush signed it into law.

National Doctors’ Day is an opportunity to recognize the dedication of physicians towards their patients. This is a day to appreciate doctors and recognize their role and leadership in the community. It also serves to raise awareness of the problems the doctors face in the day-to-day work of healing. Beyond the application of science and technology, medicine is a special calling. Those

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It is Saturday morning and though still battling a sleep deficit from the previous night’s ordeal in the Casualty Emergency Room, I have to head to my new residency posting at the National Tuberculosis and Leprosy

Programme (NTLP) in-patient wards. The “aha” insight central to the theme of this article is birthed in two occurrences on my first day here. While patients in most Western and developed countries enjoy a relatively better nursing privacy, the picture in most developing and especially African hospitals is that of an open aura-except of course in a few private settings.

On this day, a long staying male in-patient of TB pleura (recurrent bilateral effusions) is seen by his colleagues heading to the washrooms never to return. He is found dead several hours later after collapsing and hitting his head on the door. Considering his tender age, I rule out the possibility of a Vaso-Vago manoeuvre; most probably, it was respiratory distress leading to the syncope, then head injury. That same evening at the female ward, another seemingly stable two-times retreatment ISS patient develops DIB due to PCP and passes away despite all my “conventional interventions.” The following day, two male and three female in-patients request undue discharge. As I struggle to empathize with these patients, three facts became clear to me: • The dying process is quite traumatising, especially to patients (relatives and attendants aside) who shared the same ward/cubicle as the late colleague, regardless of the diagnosis and prognosis. The open aura set up does not

Is there need for a desensitization programme for patients who shared the same ward with patients who have died?

Asks Dr Misaki Wayengera

allow for privacy at this time, and the consequence is that those witnessing the scenario (and are non-medics) are traumatised. • Often, we in the medical profession take the dying process for granted, having perhaps been desensitized by our training and past experiences. To the layperson, the picture is that of his saviours (medics) failing their mission. They feel hopeless. • Death aside, what about those bedside and corridor

procedures we undertake using our seemingly ‘conventional’ yet scary manoeuvres and tools, saws, blades, name it. While these may seem routine to a medic, they are terrifying to a layman and more so when they fail to yield good results.While still caught up in trying to explain to those five patients that their stay on the ward did not mean they would be the next ones to die, it hit me hard how privacy during the dying process is much needed. What do you think? May be a desensitization programme for patients (and attendants) who witnessed a death could serve the purpose given

the high morbidity (or poverty and poor governance) rates in the developing world that do not help to improve the situation unlike in the West. Regardless, such a programme should serve to explain the reason for the occurrence of death, reduce fear and ultimately offer hope and trust in the system to the “survivor.”

Dr Misaki Wayengera is based at Makerere University, Faculty of Medicine, Kampala, Uganda.Source: Afr Health Sci. 2006 June; 6(2): 85.

Death aside, what about those bedside and

corridor procedures we undertake using our seemingly ‘conventional’ yet scary manoeuvres and tools, saws, blades,

name it

Death in hospital wards

O p i n i o n

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Disaster ManagementHow prepared are we?

By Patricia Muigai

Suppose the recent outbreak of the swine flu reached Kenya? What if a massive earthquake rocked Nairobi? Can we cope? Although large-scale calamities are not common in this part of the world, experience

shows that disasters often catch us off guard, sometimes causing damage and loss of life that is easily preventable. The disaster preparedness manager at The Kenya Red Cross Society, Mr Davis Okoko describes a disaster as any natural or manmade event that significantly affects the functioning of a community and results in destruction of property and loss of life. “Disasters overwhelm communities and they are unable to cope without help,” he says. “Disasters are classified as slow onslaught, such as drought, which leads to food crisis and sudden disasters such as a fuel tanker explosion that can cause serious injuries and mass casualties to those in the immediate vicinity.” Examples of disasters that have affected Kenyans adversely include the August 1997 terrorist attack in Nairobi, the HIV/AIDS epidemic, the 2007 post election violence and internal displacement of people among others. Okoko says that poverty is considered one of the major hindrances in preparing for, and managing disasters. “For example, buying a fire extinguisher is not likely to be a priority for poor families, yet it is a necessity in the event that a fire gets out of control.” He adds that people are always exposed and vulnerable to disasters to some extent, but the most vulnerable are children, the elderly, the disabled and women. For the women, it is not because of their gender, but the role they play in society, as the main caregivers of the other vulnerable groups.

Being forewarned is being forearmed. Okoko explains that disaster preparedness as the name suggests, means putting in place measures that put people in a state of readiness. “This is only part of the wider disaster management which covers other aspects such as response, coordination and recovery measures,” he says.

Role of government“From the national to the individual level, everyone has a role to play in disaster management, but the sole responsibility lies with the government. Currently, there is no specific disaster management policy and the approach is mostly decentralized,” says Okoko.The Ministry of Special Programmes in the Office of the President is charged with the management of disasters in Kenya. Other government stakeholders include, the Department of Defence, Provincial Administration, Kenya Police Force, Ministries of Health, Agriculture Livestock and Rural Development, Transport, Environment and Natural Resources, Local Government, and Roads and Public Works.The National Disaster Management Executive Committee (NDMEC) is the highest institution in disaster systems and falls under the MoSP. It was established to design programmes for disaster intervention, and chaired by a Cabinet Minister, and has members drawn from Government ministries. The National Disaster Coordination Committee (NDCC) is the next top-level organ in disaster management.The National Disaster Operations Centre (NDOC) translates the decisions of the NDCC into action

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M a i n F e a t u r e

or instructions and ensures that those instructions are transmitted and carried out by the ministries/departments to whom they are directed. It coordinates all disaster activities, before, during and after occurrence. In the non-governmental sector, the key stakeholders are the Kenya Red Cross, St Johns Ambulance, International Committee of the Red Cross, International Federation of Red Cross and Red Crescent Societies and AMREF. Though there is need for a national disaster management agency to integrate all these, Okoko says the advantage of this approach is that problems are dealt with by experts in specific areas. “To supplement the government’s efforts are humanitarian agencies such as the Kenya Red Cross Society, United Nations agencies, local Non-Governmental Organizations and individuals with specialized skills. Some of these agencies handle disasters within the country and across the borders,” he says.

Medical care and disasters “Whenever there is a disaster, healthcare institutions bear the brunt of it. They provide much needed assistance in emergency operations by receiving casualties, providing medical care and are responsible for handling mortal remains of victims. Sometimes specialists are needed on the ground. It is therefore important for them to be on alert to respond promptly when disaster strikes” Okoko says. However, he adds, healthcare providers have an essential role to play in preventing disasters before they happen through providing primary healthcare by creating public awareness on measures that prevent infectious diseases from occurring or spreading. In addition, disaster preparation means reaching out more to communities and having personnel, medical supplies and specialists on standby. “It is always a challenge when disasters strike in areas where hospitals are understaffed and ill equipped to offer care to victims,” he says.

What needs to be done?Taking proactive measures to invest in disaster preparedness and management undoubtedly has heavy cost implications. But then again, it costs much more in terms of damaged property and lost lives and opportunities when such measures are not taken before disaster strikes. Okoko says that currently Kenya does not have a national disaster management plan in place though a disaster management act is in the works and is yet to be passed as law by parliament. With such a policy in place, and if well implemented, he says, the impact of disasters is reduced significantly and recovery is made faster and easier. He also adds that after implementation, there should be consistency. “The public also has an important role to play in disaster management. There is need for the public to be aware of precautionary measures such as evacuation in case of a fire and how to use fire fighting equipment, training on first aid, how to minimize damage once it occurs and so on,” he says. In other words, it

means adopting a culture of minimizing risks, of being alert and knowing how to deal with crisis. Sometimes individuals place their lives in danger in an effort to rescue victims in a disaster. Though big public gatherings are a good indicator of incidents for our surveillance and monitoring team, they should not worsen the situation even as they try to help. They can do this by giving way to emergency response teams such as ambulances, fire trucks etc, and keeping a safe distance. Those with first aid skills can help without risking their own lives.

Accident and Emergency Centre The Nairobi Hospital

The Nairobi Hospital A&E Centre is the first stop for any emer-gency patient. “We see about 300-400 patients per day, and about 10 per cent of these would be real severe emergencies. Eighty to 90 per cent will be walk in patients who are basically using this as an outpatient facility,” says Dr Lwai Lume, the coordinator, A&E. “We receive many trauma victims as a result of gunshot injuries, and road accidents.” All A&E staff have undergone an emergency preparedness train-ing including advanced cardiac life support, advanced trauma life support, improve their skills in managing critical patients. The first 15-20 minutes of receiving the patient, really outlines the ability of that patient to survive. We have refresher courses constantly 2-3 times a year. “We also have skill checks in the department on a regular basis to make sure our doctors and nurses are able to handle critical pa-tients in those first emergency steps, and pass these patients on to the ICU. “ The A&E team works closely with the ICU team, so that if a patient is difficult to stabilize they can ask for assistance from the ICU. “We call consultants if the need arises to assist with patient stabilization,” Dr Lume says. The department is well equipped with facilities for monitoring car-diovascular and respiratory systems. Intubation respiratory support is carried out by a team of well-trained doctors and nurses. The A&E centre is also equipped with an ultramodern CT scan to cater for emergencies. Portable X-rays and ultrasounds are carried out within the resuscitation room when necessary. “We have a fully established disaster preparedness programme that emerged as a response to our experiences following the 1998 bombing of the US Embassy,” Dr Lume says. That is when there was a realization that the hospital needed to put in place several steps that would ensure that people are well utilised in the event of a disaster, they communicate effectively and know who to call on in the event of a disaster. The incident commander is Dr Cleopa Mailu, CEO Nairobi Hospital, during the day. After hours, it is the A&E coordinator, who ensures that the relevant people are informed. “For a disaster management program to be effective there needs to be a satisfactory level of pre arranged support. This enables quick response during disasters, proper coordination and easier recovery. Constant communication is very important and so is availability of transport. Proper triage and life support training makes it easier to manage patients. We put all these into consideration when designing our program,” says Dr Lume.

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The Kenyatta National Hospital has been involved in all the major disasters that have happened in Kenya. From the OTC bus and Norfolk Hotel bombings in the 70s, to the 1998 US embassy

bombing, Ivory Coast Kenya Airways crash in 2000, the Busia plane crash, Marsabit clashes; Nyamakima building collapse, the infamous post election violence in 2008 and the more recent Nakumatt and Molo fire tragedies, KNH has been at the forefront. These disasters were manmade and had no advance warning unlike natural disasters like floods, where hospitals may receive advance warning1.

Most of our hospitals do not have a disaster management protocol and hence there is no proper coordination when a disaster strikes. It is no surprise then that the management of disasters in Kenya has been characterized by an element of poor coordination as evidenced in the confusion noted in poor pre-hospital triage in the Nakumatt tragedy and the Molo tanker fire disaster. The initial responders were poorly coordinated and in some instances did not get free access to the victims. There were also mixed instructions and signals from leaders. However, it is noteworthy that in all the instances, professionalism prevailed and patients were adequately managed by the various government and private hospitals. Hospital disaster preparedness has taken center stage from the District, Provincial and National levels. It has become imperative that hospitals have a well-documented and tested Disaster Management Protocol (DMP).

Kenyatta National Hospital has taken a leadership role in the country’s disaster management. The leadership role of triaging patients to different hospitals in the recent Molo tragedy is a testimony of the understanding of its leadership position. An inter-ministerial coordinating committee was formed 2009 to co-ordinate the Molo fire disaster and draw-up a framework for future inter-sectoral co-ordination and networking of the medical teams. The committee is

headed by Dr. Micheni and draws membership from the Ministries of Medical Services, Ministry of Public Health and Sanitation, Ministry of Defense, National Disaster Operations Center in the office of the President and the leading Hospitals in Nairobi (Nairobi Hospital, Aga Khan University Hospital and Mater Hospital).

Kenyatta National Hospital itself has a standing committee on Disaster Management, which came up with a protocol on disaster management. This protocol was tested during the

recent major critical incidents. With the intersectoral networking, the aim is to harmonize the hospitals DMPs and revise the chapter on the Medical Disaster Management of the National Disaster Management Plan.

Preparedness for disaster is a dynamic process. In addition to a well-documented DMP, it is prudent to have regular drills. The aim is to train hospital staff to respond to a

major critical incident (MCI) validate the hospitals DMP, make new hospital staff aware of procedures in disaster response, incorporate

advancements in technology into the DMP and use reports from the drill to reinforce the DMP and improve response to patient needs2.

It is also prudent that major hospitals adopt standards that match best practices in disaster management and to have a very elaborate national coordination mechanism3. That way, Kenya will be able to cope with disasters as they arise, but more importantly identify and prevent manmade disasters.

REFERENCES1.Hospital preparedness for mass casualties, final report, by the American Hospital Association with the support of the office of the emergency preparedness, U.S. Department of Health and Human Services, August 2000 accessed 2006, April 3.2.Cook L. Hospital disaster drill game: a strategy for teaching disaster protocols to hospital staff. J. Emerg Nurs 1990; 16:269-73.3.Clinical guidelines: Joint Ministry of Health (Kenya) and WHO Publication, 2nd Edition, 2002.

Medical disaster preparedness in Kenya:Status and the way forward

By Dr J N Micheni and Dr P K Wanyoike

Violence rocked the country following the post election violence

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On the morning of October 8 2005, a 7.6 magnitude earthquake struck south Asia. The epicentre was located 95 kilometres northeast of Islamabad, the capital city of Pakistan, which

has a population of 4.5 million people. An estimated 43,000 lives were lost, 50,000 people were injured and thousands were left homeless. This was a catastrophe of great magnitude. The displaced sought refuge in camps that were set up in open fields. A disaster of this scale warranted the deployment of lead agency experts in trained in technical areas science and the disaster management, especially in co-ordination, lack of which is a leading cause of death in disasters. Many of the lead agency coordinators in Pakistan appeared ill equipped and lacked the skills required to strategize and articulate priorities to manage the situation. The World Health Organization intervened to fill the gap in humanitarian response.

Challenges The main concern was for the homeless, the most vulnerable group being infants, pregnant women and the elderly. The combination of poor shelter, overcrowding, disruption to water and sanitation services, and high pre-existing rates of under nutrition, placed these vulnerable people, at an even greater risk of illness. The main challenges that faced aid agencies included a difficult terrain, cold climate, enormous logistic problems, lack of field hospitals and slow response.

Priority health problems - General IssuesOwing to congestion and lack of amenities for the IDPs living in camps, a number of issues emerged. There was need for provision of essential medical supplies to clean wounds and prevent infection. The victims need psychosocial support and temporary shelters with protective ability against prevailing climatic conditions, placed with sufficient space between them to avoid overcrowding, which could lead to the spread of illnesses. There was a need to ensure proper water storage and the food is properly cooked.

Priority health problems - DiseasesThere were a number of priority health problems including, wounds and injuries, water, food and sanitation, overcrowding and climate and vectors and rodents. Incidences of bloody diarrhoea were high and would have been of great concern if safe water and adequate sanitation were not provided. Good personal hygiene, elementary food hygiene precautions, high quality standards for public water supplies and proper disposal of sanitary waste remained

the priority recommendation for preventing outbreaks and transmission of Hepatitis E. Provision of antibiotics for treatment of pneumonia, a leading cause of morbidity and mortality in displaced populations was required. Continuation of TB treatment needed to be ensured as interruptions in treatment could facilitate transmission in camps. Although not a leading cause of mortality during the emergency phase, TB often emerges as a critical problem, once other epidemic prone diseases have been adequately controlled.

Gaps in humanitarian responseThere was a shortage in medicine and/or other medical supplies, difficult dialogue between local and international health actors, poor coverage of and difficult access to primary healthcare, disrupted public health programmes (e.g. immunizations), poorly designed and managed camps for internally displaced people and inadequate nutrition, especially among children. The IDPs lacked sufficient access to safe water and inadequate sanitation, functioning laboratory and hospital services and referral systems.

WHO ResponseThe World Health Organisation (WHO) had four emergency teams on the ground, with 60 WHO staff working full time on earthquake relief. Up to 40 national public health experts were recruited to go to the affected regions. Their priority was to provide shelters, food supplies, and medical supplies.

Transition to Recovery and ReconstructionEarly recovery covered activities such as building transitional shelter, farm and non-farm employment, institutional and legislative capacity development especially land and property management, psychosocial support, risk mitigation and preparedness. There was also environmental rehabilitation, protection of vulnerable groups like children, women tenants and the landless, including IDPS. It also included health and education services before permanent structures were built. It also assisted with 150 prefab basic health units in addition to training female staff, and disease early warning system.

Return of IDPsSmooth return of IDPS was an important step in the transition from relief to reconstruction. The priority was to ensure that tens of thousands of families returned to their villages in a voluntary and dignified manner. Programmes were developed to ensure that essential services followed the people i.e. primary health care, basic education and food.

Disaster management: The Pakistan experience

By Dr Martin Awori (BDS, DDPH, RCS, MPH LLB)

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D i s e a s e P i c t o r i a l

Toxic epidermal necrolysis (TEN) and Steven-Johnsons syndrome (SJS)

By Dr Anne Wairimu Imalingat (Physician Dermatologist)

At time of diagnosis

TEN and SJS are common life threatening dermatological emergencies characterized by the necrolysis of the skin and mucus membranes. They usually occur secondary to drug intake.

Common drugs implicated are anti-epileptics, antibiotics, anti-tubercular agents and NSAIDS. With the advent of HIV infection there has been a multifold increase in their incidence. TEN and SJS are believed to be a part of a spectrum and a consensus classification has been formulated (Table 1).These conditions are responsible for a great deal

Case Presentation This 27-year-old patient X was diagnosed with HIV and put on anti-tuberculosis therapy for pneumonia. She was started on septrin prophylaxis and seven days later she developed a skin rash which at the onset could be diagnosed as SJS, this quickly developed into TEN.

1. Erythematous macules and peeling of the epidermis

2. Blistering on the soles

of morbidity and mortality because of temperature dysregulation, fluid and electrolyte imbalance and septicemia leading to multi-organ failure and death. They are potentially fatal diseases with a 10 to 30 per cent mortality rate. The prognosis depends upon the extent of skin and mucosal involvement and the time of initiation of therapy. Withdrawal of the offending drug is the first step in the management of this condition. Conservative management forms the main stay of therapy. It includes fluid and electrolyte replacement, nutritional support, temperature regulation, prevention and treatment of infection by daily dressing and broad spectrum of antibiotics and ophthalmic, oral and pulmonary care. The role of specific therapy is debatable and there is no universal consensus on the drug of choice. Short course of corticosteroids early in the course of disease may be used with caution. Cyclosporin and intravenous immune globulins (IVIGS) have shown variable results in different studies and may be used. Thalidomide has been proven to be detrimental and is not recommended. There is no room for drug challenges.

SJS: Epidermal detachment <10% of the Body Surface Area (BSA)

SJS – TEN overlap: Epidermal detachment is 10-30% of Body Surface Area

TEN: Epidermal detachment is >30% of Body Surface Area

(Table 1)


Just before discharge

D i s e a s e P i c t o r i a l

3. Ulceration of lips and mucous membranes of the mouth

4. Re-epithelisation occuring one week after admission

5. Blistering on the palms

6. Almost total re-epithelisation with minimum ulceration of the lips after two weeks

7. Re-epithelisation occuring one week after admission

8. Resolution of palm blisters after two weeks


D o c t o r P r o f i l e

Dr Frank NjengaLiving his dream

Dr Frank Njenga wears many hats, attending to his patients at his clinic at Upper Hill and Chiromo Lane Medical Centres, chairing various professional associations and organizations,

writing books and papers, travelling the world and making presentations. The list is endless. It is admirable how he manages to do it all. “Often, people ask how I keep it all together. My view is you can do anything you set your mind to. It is a question of discipline, of managing your time, and more importantly, wanting to do it. It is about developing efficient systems, around you designed deliberately to support you,” Dr Njenga says.

Fond childhood memoriesDr Njenga was born in Nairobi in1950 at King George the Sixth, present day Kenyatta National Hospital. “I have lived and worked within about a square mile of Kenyatta National Hospital almost entirely. I was brought up in Nairobi. My neighbours were a mixture of different tribes. In fact, I am fluent in Luo. I find it very difficult to understand how people draw boundaries on others based on their tribe. It is unnatural for me because it is something I have never experienced.” His upbringing he says completely liberated him from tribal or racial thinking. “I shudder to think that there are Kenyans who still think tribally or racially.” Dr Njenga went to King George the Sixth Primary School, now Mbagathi Road Primary School. “Some of my classmates from standard one are still my friends. Recently I hosted a number of them to lunch,” Dr Njenga says. His parents worked at the hospital but this did not influence him in any way to study medicine. “One of my fondest memories as a child is attending the uhuru celebrations at Uhuru Gardens. I sang for President Jomo Kenyatta and saw the then Duke of Edinburgh Prince Philip,” he says. For 13-year-old Dr Njenga it was an exhilarating time. In 1964, he joined Delamere High School (today UpperHill High School) becoming one of the first African students to attend the previously exclusively European school and to become head boy in form five. One of the major highlights of his secondary school days was climbing Mt Kilimanjaro. “The group that I climbed Kilimanjaro with was made up of very interesting boys including an Australian, French, New Zealander, British, Italian, and Kenyan who is still my friend,” he says. “The level of comradeship that developed as we struggled up the

mountain taught me an important lesson in accepting people regardless of tribe or race.”Education was easy for Dr Njenga. “If there was anything I did a lot of at that time, it was to read. I read novels, History, English and Philosophy outside of class,” he says. In his third form in 1966, Dr Njenga came across The Wretched of the Earth, a book written by Frantz Fanon. It is about the Algerian war of liberation against the oppressive French. “I was so impressed by Fanon’s ideas, thoughts and the entire philosophy, of why a man must do things for fellow men that I decided I wanted to be like him,” he says. He later discovered that Fanon was in fact, a psychiatrist. “I did not know what a psychiatrist was; I did not know what the difference between a psychiatrist and a psychologist was but I discovered that you cannot go to medical school unless you study science and you cannot be a psychiatrist unless you are a doctor,” he says. By the time he was 16 years, Dr Frank Njenga was confident he was going to be a psychiatrist. “I think I have been lucky, and I am happy,” he says.

Childhood dream comes trueAfter graduating from the University of Nairobi Medical School in 1975, Njenga did his internship at the Kenyatta National Hospital and worked as a medical officer for the Ministry of Health. He then left for the United Kingdom, where he studied psychiatry at Maudsley Hospital from 1977 to 1980. Dr Njenga is confident that he received the best training that prepared him for a career in psychiatry in Kenya. “Maudsley Hospital is the best and oldest training hospital for psychiatrists in the world. It opened its doors around 1350. We recently celebrated 750 years of its existence. I had what I think is the best instructions in psychiatry that money can buy. I enjoyed the three and a half years that I was there; very high level of academic stimulation and that was good,” he says. “My dream had come true.” Dr Njenga practiced at The Nairobi Hospital and taught at the University of Nairobi Department of Psychiatry before he retired from teaching in 1983. In 1997, he became chair of the Medical Advisory Committee at The Nairobi Hospital, at a time when there were very many challenges about what he calls ‘the conservative versus progressive forces’. “During my chairmanship, there was a group of ultra conservatives that did not want any kind of change.” One of Dr Njenga’s highlights during his chairmanship was when he hosted former President Daniel Moi for a fundraising


for the Accident & Emergency Department. “I was able to persuade doctors to each donate between Ksh25, 000 and 50,000. We raised more than 60 million. I felt I had played a role in community development by mobilizing a very large number of doctors to do something that would last for many years,” he says.“The other thing that really stands out in my life is when I led the Operation Recovery response following

the 1998 bomb attack. Nobody had ever responded to a terrorist attack in this part of the world and so I had to build from scratch; because there was no manual, so we had to put a very formidable response and it worked,” Dr Njenga says. “If there is anything else that has given me a professional stake, it is submitting scientific papers on strategies we put in place after the blast. With my colleagues Dr Caroline

Dr Frank Njenga with his wife Elfreda during a recent trip

to Greenland

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Nyamai and Dr Pius Kigamwa, we have published several papers in high impact journals and presented them in many parts of the world,” he adds.

First private psychiatric hospitalIn 1997 alongside Dr Marx Okonji, Dr Fred Owiti, and Dr Wairimu Ndirangu, Dr Njenga established Chiromo Lane Medical Centre, Kenya’s first, private inpatient psychiatric hospital. Some psychiatric patients could not be managed at most general hospitals because they were too psychotic or needed to stay in hospital longer and there was no facility for them in Kenya. “My colleagues and I decided to fill the gap. “Our motto is to give psychiatric patients an opportunity to recover in dignity because one of the worst things that happen to our patients is, they are denied dignity,” he says.

In 2002 they opened Bustani, an annex in the Lavington area which specializes in the care of young people in need of counselling, and offers a safe and secure environment for specialized conditions such as Attention Deficit Hyperactivity Disorder (ADHD), depression, anxiety and substance abuse. “We also specialize in cognitive behaviour therapy (CBT) for depression, addiction counselling as well as the psychoeducation of patients. We carry out computerized tests for cognition, intelligence, attention, memory as well as concentration.” He says treatment interventions in mental health have changed dramatically from the days of Largactil and locked wards. “Effective treatment options are now available. Treatments for conditions such as ADHD, depression and even drugs for alcohol related problem are available.” To Dr Njenga, professional partnership with his peers is one of the keys to success. “I have worked successfully with Dr Okonji, Dr Owiti and Dr Ndirangu at Chiromo Lane Medical Centre for almost 15 years. It is the same with Dr Anna Nguithi, my colleague at Upper Hill Medical Centre, with whom I have worked for 19 years now,” he says. To him, it is possible for doctors to work well together as long as they respect each other, are not greedy, there is trust and everyone works hard.

Fighting stigmaSociety has tended to stigmatize psychiatrists and their patients. “When you do not understand something you stigmatize it,” he says, adding that the stigma is a serious problem globally. “It is everywhere in the world, not just here. The best way to fight stigma is to give accurate information. When people are not informed they remain ignorant,” he says. Between the year 2001 and 2004 Dr Njenga hosted Frankly Speaking a television programme, which featured people with conditions such as depression, schizophrenia and alcoholism among others. The programme, he believes,

reduced the stigma associated with psychiatry and many are now able to seek help for themselves and their families. “The stigmatization of these people has become less so that now the layperson knows what psychiatrists do,” he says. Dr Njenga is also a mental health programmes consultant for the BBC. His web page on the BBC News website is a popular avenue for global communications on mental health and his series on mental health won a silver prize at the New York Radio Awards in 2003.

Accomplished authorDr Njenga has written several books, book chapters and has published extensively in scientific journals on a variety of subjects. “I have a passion for writing. I enjoy writing for children. I write stories with messages that help children to understand what mental illness is, or to understand what drugs are and drug abuse is. I also write stories to help children to understand how to relate with their parents. I have also written a book on stress and daily life,” he says. Dr Njenga also pens ‘The Coach,’ a weekly column in the Business Daily newspaper. The column addresses mental health issues in industry and the private sector in general. Dr Njenga is chair of the African Association of Psychiatrists and Allied Professions (AAPAP) and immediate past chair, Kenya Psychiatric Association. He is a member of the Kenya Medical Association, a Fellow of the Royal College of Psychiatrists, a member of American Psychiatric Association and the chairman, National Campaign against Drug Abuse Authority (NACADA) and AAR among others. “AAR’s concept is similar to a company we started with a group of friends in the 1980’s but failed due to lack of experience. I am now more experienced and confident,” he explains.Dr Njenga is married and has three adult children. He loves to read, travel and plays golf during his spare time. “I feel privileged to have travelled to many parts of the world. In my most recent trip to Greenland, I saw worrying evidence of global warming. We must protect our environment with all our might or suffer.”

Parting shot“Many doctors reach old age without a road map and if their practices start to dwindle, they get shocked that a practice can actually go down. As the old saying goes, make your hay while the sun shines. Old age will come sooner than you think,” he says. He adds, “Doctors also burn out and need to look after their health. “Physicians’ health (both mental and physical) is a much-neglected field of study. Treat yourself to a good life and enjoy your relationships with friends and family.”

D o c t o r P r o f i l e

Additional reporting by Patricia Muigai

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Founded by Dr Prakash K Patel, Cosmos Limited was incorporated 30 years ago. As chairperson and managing director of Cosmos, Dr Patel’s vision is to create a centre of excellence to provide cost effective

essential, quality drug products for Kenya and neighbouring countries. “Before Cosmos, pharmaceuticals were imported. Few essential drugs were manufactured in Kenya. Cosmos began to manufacture pharmaceuticals with the aim of making Kenya self sufficient in essential drugs. Today many essential drugs, including anti malarial, anti TB and ARVs are produced locally with the same quality and efficacy as the imported ones,” says Dr Patel who is a pharmacist. Over the years, Cosmos has established itself as a reputable manufacturer. It is ranked as one of the leading pharmaceutical manufacturer in Kenya and the East African region, boasting state-of-the-art manufacturing equipment, well equipped formulations, development and analytical facilities, ISO class 8 manufacturing area for tablets/capsules, and good supporting utilities. The facility provides employment to about 400 people. Commitment to quality, a clear vision, quest for

COSMOSProviding cost effective pharmaceutical products

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Managing Director and Chairman of Cosmos Ltd, Dr Prakash Patel

By Patricia Muigai


A D V E r T O r I A L

continuous improvement, motivated and committed staff and teamwork has contributed to the growth of Cosmos. A board of directors and professional managers including six pharmacists manage Cosmos.

Range of products Cosmos manufactures ethical, consumer and veterinary. Cosmos is committed to availing safe and efficacious high quality medicines at affordable prices. Their range of products for human and veterinary use include analgesics, antipyretics, anti-allergens, anti-bacterial, diuretics, psychotherapeutic drugs, gastro-intestinal, anti-epileptic drugs vitamins and minerals among others. Cosmos is currently the license holder from Glaxo Group Ltd and Boehringer Ingelheim International for the manufacture of ARVs in Kenya. “We compete with foreign companies very well on veterinary products. We export to Uganda, Tanzania and other East African countries, though the market is limited because people will only spend money when they have it,” Dr Patel says.

ChallengesCosmos aims to be the leading pharmaceutical manufacturer in the sub-Saharan region. To achieve this goal they need more support from the government. “There is still much that the government can do to support local manufacturers. If there are many manufacturers of a certain product, then the government should try to restrict importation. At the



Corn products

moment it is a free market and anyone can import or export provided the product is registered.”Local manufacturers need protection from unfair competition and double standards in intellectual property. “There is little industry protection even though our products are registered.” He says that some foreign countries do not recognize multi patent intellectual rights so they can export anything to Kenya, patented or not. “We as Kenyan manufacturers can register our product but we cannot manufacture it and put it in the market. Foreign companies can always bring their products and market them while we as Kenyan manufacturers cannot do it because it is against the law.” Though competition is stiff, Cosmos has adopted growth strategies that enable them to compete favourably. They include commitment to quality, satisfying customer needs and quality after sale service. Dr Patel says that manufacturers are making huge losses due to counterfeit products. “This must be prevented. Those who sell counterfeits should not be allowed to sell and should be charged in court. One of the solutions is to buy local as much as possible as long as quality is assured,” he says.

Corporate social responsibilityAs part of Cosmos’ Corporate Social Responsibility, the Prakash Patel Foundation runs two public subsidized

clinics on Lunga Lunga Road and AMURT clinic in Kangemi. Dr Patel says that the clinics have proven that locally manufactured pharmaceuticals can treat diseases cost effectively. Cosmos is also involved in a project for feeding the poor at Mji Wa Huruma. Cosmos intends to continuously improve operational efficiency and intensify their marketing effort in Kenya and neighbouring countries, expand to other markets in Africa and Middle East. q


By Prof Walter Mwanda

Haemophilia:Life long doctor-patient partnership

The area of the bleed will seem

warmer than the surrounding areas,

as if you have passed your hand over a

candle flame

F e a t u r e

Like many other non-communicable diseases in the developing world, haemophilia is one of the diseases reserved for some specialists and specialties treated only in a few health service facilities. However, like

most inherited and congenital disorders this is a lifelong malady fraught with perhaps worse complications than the disease itself. Furthermore, although individuals manifest with the condition, the ramifications go beyond the individual; the entire family, community and the medical fraternity are involved far more than may be obvious. It is against this background that there is need to appreciate the salient features of this disease.

Types of HaemophiliaHaemophilia is a bleeding disorder due to a defect in a clotting factor level of the involved factor, which is missing, or the level is low. There are two different types of haemophilia; factor VIII deficiency haemophilia A and factor IX deficiency haemophilia B. Each type of haemeophilia can be:Mild 5%-30%, moderate 1%-5%, Severe less than 1% of normal clotting factor activity.

Inheritance patternsHaemophilia is inherited as a sex linked recessive disorder. Females are carriers and males manifest the disease. Daughters of carrier mothers have a 50 per cent chance of being carriers, daughters of haemophilia fathers are obligate carriers. Carrier mothers have a 50 per cent chance of transmitting the gene to their male children who would be ‘haemophilias’.

Status in KenyaKenya has an estimated 4,000 haemophilia A and 400 haemophilia B sufferers. However, those registered with

Kenya Haemophilia Association are less than 10 per cent. The question is where are they? The medical settings must be interacting with them occasionally. What needs to be done is to offer more adequate management to stop the bleeding relieve the symptoms and minimize complications.

Common signs Bleeding can happen anywhere inside or outside the body because of injury or trauma. People with haemophilia bruise easily and bleed for a longer time after being cut, having a tooth removed, surgery, or injury. Sometimes bruising is noticed and no cause can be remembered. This is

spontaneous bleeding most likely the result of an injury too minor to be consciously recognized. Babies bruise easily when they become mobile. They also bleed longer than usual after receiving immunization injections and injury, especially to the mouth and tongue. As children grow, spontaneous bleeding becomes more common, affecting the joints and muscles, mainly the weight bearing areas of the body.

Assessing joint and muscle bleedsBleeding inside joints and muscles poses major problems with haemophilia. Joints are surrounded by a synovial membrane with many small blood vessels. Trauma or even minor injury to joints can rupture the capillaries in the

synovium and cause bleeding into the joints cavity. Bleeding causes the joints to swell and become painful and difficult to move. Joint bleeds predominantly affect the knees, elbows and ankles but can also happen in toes, shoulders and hips. Repeated bleeding into the same joint causes haemophilic arthropathy and the development of haemophilic arthritis. Patients, health care professionals and caregivers can assess


F e a t u r e

Haemophilia is a bleeding disorder

due to a defect in a clotting factor level

of the involved factor, which is missing, or

the level is low

joint bleeds by touch: Place the back of your hand about one cm away from the skin of the affected area. Move your hand back and forth along the limb. Normally, the muscle area should feel slightly warmer than the joint area. If there is a joint bleed, the joint area will feel warmer, similar to passing your hand over a candle flame.It is very important to recognize bleeds as they occur and stop the bleeding as quickly as possible. The more blood that gets into the joint, the harder it is for the bleed to clear up. Sometimes a new bleed starts before the old bleed has cleared away. The knees, elbows and ankles bleed more often than the other joints. This is due to a number of factors: The knee, elbow and ankle joints only move in two directions bending and straightening, like a hinge on a door – whereas hip and shoulder joints can move around in all directions, like a ball in a socket. Joints that can move more freely are not often affected by bleeds. Protective muscles do not surround these joints. The knee, elbow and ankle muscles are attached to the bones above and below the joints. Only the tendons cross over the joints, so the joints are not protected on all sides. Many strong muscles cover hip and shoulder joints.Each joint has its own preferred position when it is bleeding and the patient automatically tends to move the joint into the position of maximum comfort. Specific Joints:Elbow: partly flexed, hand towards shoulder. Attempts to straighten the arm are painful and motion will be limited.Knee: partly flexed, heel towards the body.Ankle: partly extended, resting with the foot and toes pointed down away from the body.

Long-term effects of joint bleed The synovial membrane lining the joint becomes thickened and inflamed from bleeds. As the synovium thickens, it is easier for it to be pinched and torn, which starts a new bleed. With repeated bleeding in a joint, the synovium becomes chronically inflamed and eventually hypertrophies, causing

the joint to appear extremely swollen. This stage is chronic synovitis and without treatment, persistent chronic synovitis and recurrent joint bleeds can cause irreversible damage to the joint cartilage leading to haemophilic arthropathy with loss of motion, limb deformity and persistent pain. Therefore, it is very important to prevent joint deterioration from occurring. Some ways to prevent permanent joint damage are to treat each bleed immediately, rest the joint to give it time to heal, exercise to keep the joint moving once the bleeding stops and implement prophylaxis.

Muscle BleedsBleeds can happen to muscles anywhere in the body following a direct blow, a sudden stretch or sprain, or an intramuscular injection. Bleeding occurs when the capillaries in the muscle are injured. Bleeds often involve a group rather than a single muscle. The bleed may be spontaneous. During the bleed, the muscle becomes stiff, swollen and painful to stretch or touch. Swelling may put pressure on nerves, causing tingling and numbness. Patients may feel a

“pins and needles” sensation and loss of function. Like all other bleeds, early recognition and treatment is important to prevent permanent damage. Again, patients, healthcare professionals and caregivers can assess muscle bleeds by touch. Assess for warmth by holding the back of your hand about one cm away from the skin. Move your hand back and forth slowly along the limb. The area of the bleed will feel warmer than the surrounding areas, as if you have passed your hand over a candle flame. There may be bruising if the bleed is near the skin. However, bruising is not always present, or may appear one or two days after the bleed starts. In cases, where the bleed is deep inside the muscle, there is no visible bruising.

The thigh, calf, bicep, forearm and hip muscles have a great

tendency to bleed. Bleeds in the thigh and forearm muscles are experienced as tingling or “pins and needle” because pressure on nerves can cut off blood oxygen supply. Permanent nerve damage, muscle death and deformities can occur if the bleeding is not treated quickly. Each muscle has a particular position of maximum comfort when a muscle bleed occurs: >>


Central nervous system haemorrhage/

head trauma is a medical emergency

and a major cause of death in haemophilia, especially in children

F e a t u r e

Hamstring (at the back of the thigh): The knee is flexed with the heel toward body. Calf: The toes point down and the knee is slightly bent. Biceps (the upper arm): The elbow is flexed with the hand toward shoulder. Forearm (palm side): The fingers are bent into a fist and the wrist is bent. Forearm (back of arm): The wrist and hand are extended back and the fingers prefer to stay open Psaos (front of hip): The hip is bent with the thigh toward the chest and the back may be arched more than usual. When a bleed is in the recovery stage, it becomes easier to move the muscles out of their maximum comfort position.

Repeated bleeds lead to muscle scarring and weakness and due to disuse atrophy. The damaged muscles cease to protect joints, can bleed and become damaged from abnormal stresses. Untreated muscle bleeds can lead to permanent damage to muscles, nerves and joints and deformity that affects how a person sits, stands and walks.

Rehabilitation following muscle bleeds is very important to prevent long-term problems. Early treatment followed by physical therapy will help maintain good function. After the bleeding has stopped, exercises must be done consistently so that the muscle can stretch and move normally again. A physical therapist should supervise this rehabilitation process. If possible, begin a scheduled infusion of factors such as prophylaxis.

Bleeding within the head or into the nervous system can be life threatening. Symptoms include headache, nausea, vomiting, sleepiness, confusion, clumsiness, weakness and drowsiness. Throat and neck haemorrhages are also very serious bleeds in people with haemophilia. They are accompanied by swelling or difficulty in swallowing or breathing. Central nervous system haemorrhage/head trauma is a medical emergency and a major cause of death in haemophilia, especially in children. All significant

traumatic head injuries, confirmed or suspected, as well as significant headaches, should be treated as a possible intracranial bleed. If any of the symptoms are evident, this is an emergency even if assessment is not complete.

Treatment of BleedsTreatment and prevention of bleeds are key to improving health and quality of life for people with haemophilia. Simple measures applied as soon as a bleed is recognized can help stop a bleed more quickly and prevent long-term damage. Haemophilia is treated by replacing missing clotting factor in blood. Factor therapy is used to treat haemophilia A

(factor VIII deficiency); haemophilia B (factor IX deficiency); and other clotting factor deficiencies (I, II, V, VII, X, XI and XIII). The missing factor is injected intravenously; bleeding stops when enough clotting factor reaches the bleed site. Treatment must be given as quickly as possible to prevent long-term damaged.Access to blood products is key to the ability to lead a normal active life. Without factor replacement products, patients face a life of chronic pain and increasing disability. All medicine should be checked with a haemophilia specialist. Medicine and treatment products must be stored and used according to instructions. People with haemophilia should not take acetylsalicyclic acids (ASA or Aspirin) in any form to reduce pain. Nonsteroidal anti-inflammatory drug (NSAIDS) should not be taken

without medical advice.Beware that for the person with haemophilia and family members, feelings and thoughts may alternate from optimistic and constructive to pessimistic and destructive. This is normal in the gradual process of accepting haemophilia and learning to live a normal and productive life in spite of the disorder. Because haemophilia is a chronic life condition, people with haemophilia must be encouraged to accept they will always be “the patient”.

Learning how best to integrate haemophilia into daily life will help patients have a proactive attitude towards the condition and enable them to take control of their lives without taking unnecessary risks.

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Founded in 1947, Gertrude’s Children’s Hospital is a charitable trust run by a board of trustees responsible for all hospital policy decisions. It opened its doors as a relatively small 16-bed facility but has grown

over the last 62 years to an 80-bed facility. Located in the Muthaiga area in Nairobi, Gertrude’s Children’s Hospital is a dream turned reality. The hospital has succeeded in fulfilling their long-standing dream to be a focal point of paediatric excellence. The facility is a one-stop centre providing every procedure that any child may require. Expansion at the hospital includes a state-of-the-art outpatient department conveniently adjacent to a pharmacy and laboratory. Today, Gertrude’s is an ISO certified facility committed to excellence in paediatric care.

ISO certificationIn 2008, Gertrude’s received the 1S0 9001:2000 standardisation certificate. Hospital CEO, Gordon Odundo says, “Implementation of ISO 9000 required standardisation of our inpatient and outpatient services. Gertrude’s hopes to apply modern quality techniques which result in customer satisfaction with staff members being committed that all our processes, costs, service times will improve and not decline.”

Satellite ClinicsGertrude’s is committed to taking healthcare to the patient rather than bringing the patient long distances to the

GERTRUDE’S CHILDRENS HOSPITALSetting Paediatric Healthcare

Standards in Kenya

we are proud to be the provider of CT/MRI/Nuclear

medical services for patients from G.G.C.H.

DIAGNOSTIC CENTRE KENYAP.O BOX 39398 - 00623 PARKLANDS

NAIROBI KENYA, FAX: 3750016

DIAGNOSTIC CENTRE KENYAM.R.I, NUCLEAR MEDICINE, X-RAY, ULTRA SOUND, OPG AND SPECIAL EXAMINATIONS

MUTHITHI ROAD - TEL: 3740046, 3748058, 3744173

CT SCAN DEPARTMENT - M.P. SHAH HOSPITAL - TEL 3744420 / 3744453

RADIOTHERAPY AND MAMMOGRAPHY DEPARTMENT - NAIROBI HOSPITAL - TEL: 2725474 / 2725475

E- mail: [email protected] Website: www.dckenya.com

Githogoro Clinic, an outreach project supported by Gertrude’s Children’s Hospital. The clinic offers free quality medical care to both adults and children including VCT and nutrition

A view of the new ultra modern outpatient department, which includes a pharmacy, laboratory and doctorsconsulting rooms



hospital. To this end, Gertrude’s has established a network of outpatient satellite clinics within Nairobi. In 2003 we opened the first satellite clinic in Lavington, in 2004 and 2006, 2008 we opened further clinics in Doonholm, Nairobi West, Pangani and most recently Gertrude’s has opened a fifth satellite clinic in Embakasi. The satellite clinics have gone a long way in eliminating congestion and delays caused by heavy traffic in the main hospital, located in Muthaiga.

Training CentreGertrude’s was the first hospital in Kenya to offer a specialized one-year training course in Paediatric Nursing, to all state registered nurses. The training centre is also a venue for workshops and other training courses on selected subjects. Approximately 100 nurses have graduated from the training school. Gertrude’s has also consistently been the main Paediatric Advanced Life Support (PALS) emergency training centre since 1999, in Nairobi and in Mombasa. From early 2008, Gertrude’s in conjunction with the World Diabetes Foundation, Aga Khan University and University of Nairobi has been offering a six-month course in Paediatric Endocrinology.

Corporate Social ResponsibilityOver the last seven years, Gertrude’s has developed an ever-increasing portfolio of CSR projects. The Githogoro Clinic is an integral unit of Gertrude’s CSR programme. Opened in 2004, the clinic was previously a cramped, mabati one-room structure. Following a USD15,000 grant from the Clinton Foundation, Gertrude’s has been able to build a large, efficient and patient friendly clinic with a laboratory, pharmacy, counselling and general waiting area. In collaboration with The Smile Train a US based charity, Gertrude’s has set up a programme to treat children with disfiguring cleft lips and palates in Kenya, free. Smile Train meets one-third of the cost, hospital surgeons and anaesthetists provide their services at minimal cost and the hospital picks up the rest of the costs. Paediatric chemotherapy is a costly procedure. For this reason, Gertrude’s has a special bank account and fundraising drive to provide free treatment to children with cancer, through its Paediatric Cancer Management Programme. Finally, the Comprehensive Care Clinic targets mothers and children from impoverished backgrounds and provides them with antiretroviral drugs.

AWARD WINNING STAFF AND HOSPITAL

2008Institute of Certified Public Accountants – FIREAwards Winner in the Not for Profit

category2007

Institute of Certified Public Accountants – FIRE Award 1st Runner up in the Not for Profit category ,

Cleaner Production Award Winner in the sub category of Occupational Health and Safety,

2nd Runners up in Waste Water Management Solid Waste Management, Gaseous Emissions and in Overall category

Best Theatre Nurse. Leah Asami a senior theatre nurse. This award is geared to recognize the best all round theatre nurse

2006Corporate Citizenship. winner Company of the Year Awards (COYA)

Joyce Musandu Trophy (Awarded by National Nurses Association of Kenya) Winner Beatrice Muyonga, a nurse in ICU.

2005Small and Medium Enterprises (SME) for excellence in management and integrity

Company of the Year Awards (COYA) Lieviens Lanckman (Award by National Nurses Council of Kenya) Best performance in

Patient CareMarketing Society of Kenya, Warrior Awards 2nd Runner up in category of Best

development of an existing brand2004

Marketing Society of Kenya, Warrior Awards Runner up Best Innovation of Service or Brand

The Professional Training Centre has a fully equipped computer lab and modern library to cater for the students and staff at the hospital



Documents

Doctors News, Volume 9 / 2009 – 1 · PDF fileOur Doctor Profile in this issue is renowned psychiatrist, Dr Frank Njenga. He talks about his passion for psychiatry and his efforts