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Pediatric surgery in Kenya
Pediatric
Surgery in Kenya By Julius Kyambi Nairobi,
Kenya
T
HE HONOR bestowed on my country and me by the Surgical Section of the American Academy of Pediatrics is much cherished. I bow in gratitude to you for having chosen me to address this august assembly. I thank you for allowing me to speak here, moreover to speak of a matter that has become the centerpiece of my life, namely, how to provide pediatric surgical services in Kenya. Although Kenya is one of the luckier Third World countries, she nevertheless is hamstrung by the same triad of poverty, disease, and ignorance that bedevils the whole of the Third World. To my knowledge, I am the first overseas guest at a meeting of this illustrious Academy who hails from the Third World. Therefore, I shall for a moment dwell on the predicament of that large section of the human community. Indeed, 75% of the world’s population live in countries for which this predicament applies. One should have thought that some 45 years after the founding of the United Nations, 25 years after the first man walked on the moon, in an age when hearts and livers can be transplanted, when the humble inhabitants of the colon can be put to work to produce human insulin-there should be no hunger, there should be no lack of simple clothing or shelter, and there should be clean water available to all. Contemporary history has another lesson for us, for after an initial phase of improvement, the Third World is now experiencing deterioration of economic and social conditions. Now there is the most dreadful of ills emerging-namely, loss of hope, which is bound to be followed by disintegration of the social fabric. In the United States, like in the rest of the rich western world, it is customary to explain the plight of the Third World as a self-inflicted phenomenon. The population explosion and the rampant mismanagement of political, economic, and environmental affairs, corruption, and armed conflicts are cited. Indeed, there is reason to be ashamed of some of our leaders and of many of our habits and practices. But European history is replete with examples of what happens when religions or ideologies clash, when ancient orders decay, when new technologies, particularly those of warfare, become available. Also, some of the wealth of the western world is based on the trade in lethal weapons with which we in the Third World unsuccessfully attempt to countermand population growth. Our increasing deficit in food production is in no small measure related to the protection of the farmer in Journal
of Pediatric Surgery, Vol 25, No 10
(October). 1990: pp 1085-1087
the northern hemisphere. The fluctuation of commodity prices reflects an outdated mechanism of global resource management. Global disequilibrium and poverty, ignorance, and disease create the niches in which parasitic regimes, corruption, and violence thrive. Ironically, the burdensome increase of population itself is a partial success of technological influx. In Kenya, the population growth is a phenomenal 3.9% per annum, but 130 of every 1,000 born will die within the first year of their life, versus 13 in the US. This difference of one order of magnitude reflects the statistics of disequilibrium manifested by the fact that 75% of the world’s population grows 30% of the world’s food grain and consumes 15% of its energy. The most depressing aspect of this global mismanagement is to allow immense numbers of children to die-to die of easily preventable or easily treatable conditions. But for every one who dies there are scores who are maimed, crippled, or otherwise handicapped, blind or deaf. It is not a matter of sentimentality or even of charity to rally against such disaster. It is common sense to avoid waste, of life, of health, of energy, and of hope and love. Forty-five years after the founding of the United Nations such distortions cannot any more be explained as manifestations and handicaps of geography and history, they are clearly evidence of global mismanagement. There were times when mismanagement expressed itself in the form of overoptimism, when it was thought that all the Third World needed was to copy the organization structures of the West (or for that matter, the East), imitate its institutions and import its technology. That this approach has failed is demonstrated by the accelerating decay of our cities (rarely more than 100 years old), of the disintegration of “imitation” institutions, be they political, educational or even industrial. They are to be found in the ubiquitous cemetry of modern technology. Hopefully, the world is awake to the necessity of inventing new approaches to progress.
From Kenyatta National Hospital, Nairobi, Kenya. Presented at the 38th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Chicago, Illinois. October 21-23.1989. Dr Kyambi was the Surgical Section’s Honored Overseas Guest. Address reprint requests to Julius M. Kyambi, MD, FAC. Kenyatta National Hospital. PO Box 19676, Nairobi. Kenya. 0 1990 by W.B. Saunders Company. 0022-3468/90/2510-0016$03.00/0
1086
In medical matters-for now I wish to focus on this narrower field more familiar to us-my country, like most Third World countries, has, with the help of the World Health Organization (WHO), adopted a strategy focused on primary health care. The major ingredients of this strategy and the concomitant massive restructuring of the health sector are to reach the population in its very habitat. That is, in the rural areas to unify the educational and other preventive activities with therapeutic endeavors at community level; to employ appropriate technology and to adjust teaching and training accordingly. In the early phase of this restructuring there was an antihospital, anticlinician trend, an overcompensating sentiment that overlooked the fact that the primary treatment of many common and simple pathological conditions is instant and simple surgery. In Kenya we are in the middle of this restructuring procedure. The health centers are in place, staffed by registered nurses or clinical officers. The 5 1 districts all have hospitals (the missionary institutions complementing the government facilities). In the provincial hospitals there are specialist services, at least as far as the major subspecialties are concerned. Then in Nairobi there is the Kenyatta National Hospital-the main teaching and referral institution. One could say that the major structural elements are in place and if the health budget were larger and the management more competent, then there would be drugs and instruments and equipment everywhere. Given the remarkable increase in the numbers of doctors and nurses and other health workers, all should be well. But all is not well. There are no drugs in the health center and there is no kerosene for the refrigerator that contains perishable vaccines. The Land Rover has broken down. The bridge on the way to the next hospital has been washed away. I could go on and describe Third World realities to you ad infinitum. I could tell you that the doctors and the nurses in the hospitals have not really been trained for the job they are supposed to tackle. Even more problematic is the question of who should do what and where-for instance, who should operate on which children, where and how. I did not come here to pretend that we have found solutions to these questions or even to hint that I know the answers. I know that whatever the solution to our problems, it will not be along traditional lines. There will not be a board certified pediatric surgeon in every hospital for many years to come nor will every child be brought to a central referral unit. Perhaps we ought to take the path that you Americans have followed when you were faced with the problems of establishing health care for children. In
JULIUS KYAMBI
many of your cities you built children’s hospitals. Perhaps we should build a children’s hospital in Nairobi and develop it into the principal referral, teaching, and research institution for the health and diseases of children in the East African region. Should the Nairobi children’s hospital be a university hospital, a government hospital, or an independent institution carried by a foundation? In this matter we need your advice. Indeed, we might need your help with manpower and we surely would like to see our children benefit from your proven generosity. Instead of continuing in this philosophical vein, I now wish to present to you what we have done so far in the field of pediatric surgery in Kenya. I would have liked to avoid statements of a personal nature, but I think it is relevant and, therefore, important to say that I had my undergraduate and postgraduate training in West Germany. When I returned to my country 11 years ago, I was the only pediatric surgeon. After a little while, I was able to establish a pediatric surgical unit in the teaching hospital. I have trained several pediatric surgeons who currently practice in Kenya. But, more importantly, I have shown to many general surgeons and other doctors how some surgical conditions in children should be treated. The pediatric surgical unit is small, cramped, understaffed, underequipped, and has constantly to fight for access to the scarce resources of the hospital: x-ray facilities, laboratory investigations, and operating theater time. We usually have 65 children in 45 beds. There are five doctors and 15 nurses working with me and we manage to operate on 600 children per year. These children who are referred to us from Kenya and neighboring countries come to us with all the conditions with which you are familiar. Every chapter, every page of the most comprehensive textbook on pediatric surgery is represented in our patient population, who also have scores of other strange diseases not mentioned in textbooks. They often come with advanced disease and with complications. After 11 years, I have not ceased to be amazed at the endurance, the resilience, and the mental resources of children in the face of chronic disease. I have brought with me material relative to 5,864 children we have seen in this unit and I intend to show you some slides. I do so with great trepidation, for the quality of these slides is poor. These poor slides correspond to the quality of our instruments, our equipment, and our theater environment. Nevertheless, I hope that the slides will help to convey the information that I wish to share, just as in spite of poor equipment and instruments, we did manage to help some of these children.
PEDIATRIC SURGERY IN KENYA
At this point Dr Kyambi presented slides dealing with his clinical experience with 5,844 pediatric surgical patients. Having shown a motley collection of our work, I now have to comment that I am certain that many of you will have spotted shortcomings and will have justified misgivings. Please be forthcoming with criticism and with suggestions. But also, please remember that although the principles of surgery are universal, there are no globally applicable solutions to even the most common surgical problems. The subculture of surgery has to fit into the realities of life in a given environment. 1 have tried to give a glimpse into the work of my little unit in distant Kenya. I have tried to imbue my report with observations of a philosophical nature,
1087
alluding to the state of health care in my country in particular and to the state of the Third World in general. I hope that my presentation will enable you to think of Kenya like it was next door and that you will feel that our problems are your problems as well. If I succeed in this respect, the fate of my patients is bound to improve. I do thank you again for inviting me and for patiently listening to my introductory remarks. Health-or rather the lack of it-dwells at the interface of nature and culture and I felt that it is my duty to my patients and to my audience to put pediatric surgery in a wider frame than is usual at surgical gatherings. If you judge this to have been pretentious, please forgive me.
Surgery in Kenya By Julius Kyambi Nairobi,
Kenya
T
HE HONOR bestowed on my country and me by the Surgical Section of the American Academy of Pediatrics is much cherished. I bow in gratitude to you for having chosen me to address this august assembly. I thank you for allowing me to speak here, moreover to speak of a matter that has become the centerpiece of my life, namely, how to provide pediatric surgical services in Kenya. Although Kenya is one of the luckier Third World countries, she nevertheless is hamstrung by the same triad of poverty, disease, and ignorance that bedevils the whole of the Third World. To my knowledge, I am the first overseas guest at a meeting of this illustrious Academy who hails from the Third World. Therefore, I shall for a moment dwell on the predicament of that large section of the human community. Indeed, 75% of the world’s population live in countries for which this predicament applies. One should have thought that some 45 years after the founding of the United Nations, 25 years after the first man walked on the moon, in an age when hearts and livers can be transplanted, when the humble inhabitants of the colon can be put to work to produce human insulin-there should be no hunger, there should be no lack of simple clothing or shelter, and there should be clean water available to all. Contemporary history has another lesson for us, for after an initial phase of improvement, the Third World is now experiencing deterioration of economic and social conditions. Now there is the most dreadful of ills emerging-namely, loss of hope, which is bound to be followed by disintegration of the social fabric. In the United States, like in the rest of the rich western world, it is customary to explain the plight of the Third World as a self-inflicted phenomenon. The population explosion and the rampant mismanagement of political, economic, and environmental affairs, corruption, and armed conflicts are cited. Indeed, there is reason to be ashamed of some of our leaders and of many of our habits and practices. But European history is replete with examples of what happens when religions or ideologies clash, when ancient orders decay, when new technologies, particularly those of warfare, become available. Also, some of the wealth of the western world is based on the trade in lethal weapons with which we in the Third World unsuccessfully attempt to countermand population growth. Our increasing deficit in food production is in no small measure related to the protection of the farmer in Journal
of Pediatric Surgery, Vol 25, No 10
(October). 1990: pp 1085-1087
the northern hemisphere. The fluctuation of commodity prices reflects an outdated mechanism of global resource management. Global disequilibrium and poverty, ignorance, and disease create the niches in which parasitic regimes, corruption, and violence thrive. Ironically, the burdensome increase of population itself is a partial success of technological influx. In Kenya, the population growth is a phenomenal 3.9% per annum, but 130 of every 1,000 born will die within the first year of their life, versus 13 in the US. This difference of one order of magnitude reflects the statistics of disequilibrium manifested by the fact that 75% of the world’s population grows 30% of the world’s food grain and consumes 15% of its energy. The most depressing aspect of this global mismanagement is to allow immense numbers of children to die-to die of easily preventable or easily treatable conditions. But for every one who dies there are scores who are maimed, crippled, or otherwise handicapped, blind or deaf. It is not a matter of sentimentality or even of charity to rally against such disaster. It is common sense to avoid waste, of life, of health, of energy, and of hope and love. Forty-five years after the founding of the United Nations such distortions cannot any more be explained as manifestations and handicaps of geography and history, they are clearly evidence of global mismanagement. There were times when mismanagement expressed itself in the form of overoptimism, when it was thought that all the Third World needed was to copy the organization structures of the West (or for that matter, the East), imitate its institutions and import its technology. That this approach has failed is demonstrated by the accelerating decay of our cities (rarely more than 100 years old), of the disintegration of “imitation” institutions, be they political, educational or even industrial. They are to be found in the ubiquitous cemetry of modern technology. Hopefully, the world is awake to the necessity of inventing new approaches to progress.
From Kenyatta National Hospital, Nairobi, Kenya. Presented at the 38th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Chicago, Illinois. October 21-23.1989. Dr Kyambi was the Surgical Section’s Honored Overseas Guest. Address reprint requests to Julius M. Kyambi, MD, FAC. Kenyatta National Hospital. PO Box 19676, Nairobi. Kenya. 0 1990 by W.B. Saunders Company. 0022-3468/90/2510-0016$03.00/0
1086
In medical matters-for now I wish to focus on this narrower field more familiar to us-my country, like most Third World countries, has, with the help of the World Health Organization (WHO), adopted a strategy focused on primary health care. The major ingredients of this strategy and the concomitant massive restructuring of the health sector are to reach the population in its very habitat. That is, in the rural areas to unify the educational and other preventive activities with therapeutic endeavors at community level; to employ appropriate technology and to adjust teaching and training accordingly. In the early phase of this restructuring there was an antihospital, anticlinician trend, an overcompensating sentiment that overlooked the fact that the primary treatment of many common and simple pathological conditions is instant and simple surgery. In Kenya we are in the middle of this restructuring procedure. The health centers are in place, staffed by registered nurses or clinical officers. The 5 1 districts all have hospitals (the missionary institutions complementing the government facilities). In the provincial hospitals there are specialist services, at least as far as the major subspecialties are concerned. Then in Nairobi there is the Kenyatta National Hospital-the main teaching and referral institution. One could say that the major structural elements are in place and if the health budget were larger and the management more competent, then there would be drugs and instruments and equipment everywhere. Given the remarkable increase in the numbers of doctors and nurses and other health workers, all should be well. But all is not well. There are no drugs in the health center and there is no kerosene for the refrigerator that contains perishable vaccines. The Land Rover has broken down. The bridge on the way to the next hospital has been washed away. I could go on and describe Third World realities to you ad infinitum. I could tell you that the doctors and the nurses in the hospitals have not really been trained for the job they are supposed to tackle. Even more problematic is the question of who should do what and where-for instance, who should operate on which children, where and how. I did not come here to pretend that we have found solutions to these questions or even to hint that I know the answers. I know that whatever the solution to our problems, it will not be along traditional lines. There will not be a board certified pediatric surgeon in every hospital for many years to come nor will every child be brought to a central referral unit. Perhaps we ought to take the path that you Americans have followed when you were faced with the problems of establishing health care for children. In
JULIUS KYAMBI
many of your cities you built children’s hospitals. Perhaps we should build a children’s hospital in Nairobi and develop it into the principal referral, teaching, and research institution for the health and diseases of children in the East African region. Should the Nairobi children’s hospital be a university hospital, a government hospital, or an independent institution carried by a foundation? In this matter we need your advice. Indeed, we might need your help with manpower and we surely would like to see our children benefit from your proven generosity. Instead of continuing in this philosophical vein, I now wish to present to you what we have done so far in the field of pediatric surgery in Kenya. I would have liked to avoid statements of a personal nature, but I think it is relevant and, therefore, important to say that I had my undergraduate and postgraduate training in West Germany. When I returned to my country 11 years ago, I was the only pediatric surgeon. After a little while, I was able to establish a pediatric surgical unit in the teaching hospital. I have trained several pediatric surgeons who currently practice in Kenya. But, more importantly, I have shown to many general surgeons and other doctors how some surgical conditions in children should be treated. The pediatric surgical unit is small, cramped, understaffed, underequipped, and has constantly to fight for access to the scarce resources of the hospital: x-ray facilities, laboratory investigations, and operating theater time. We usually have 65 children in 45 beds. There are five doctors and 15 nurses working with me and we manage to operate on 600 children per year. These children who are referred to us from Kenya and neighboring countries come to us with all the conditions with which you are familiar. Every chapter, every page of the most comprehensive textbook on pediatric surgery is represented in our patient population, who also have scores of other strange diseases not mentioned in textbooks. They often come with advanced disease and with complications. After 11 years, I have not ceased to be amazed at the endurance, the resilience, and the mental resources of children in the face of chronic disease. I have brought with me material relative to 5,864 children we have seen in this unit and I intend to show you some slides. I do so with great trepidation, for the quality of these slides is poor. These poor slides correspond to the quality of our instruments, our equipment, and our theater environment. Nevertheless, I hope that the slides will help to convey the information that I wish to share, just as in spite of poor equipment and instruments, we did manage to help some of these children.
PEDIATRIC SURGERY IN KENYA
At this point Dr Kyambi presented slides dealing with his clinical experience with 5,844 pediatric surgical patients. Having shown a motley collection of our work, I now have to comment that I am certain that many of you will have spotted shortcomings and will have justified misgivings. Please be forthcoming with criticism and with suggestions. But also, please remember that although the principles of surgery are universal, there are no globally applicable solutions to even the most common surgical problems. The subculture of surgery has to fit into the realities of life in a given environment. 1 have tried to give a glimpse into the work of my little unit in distant Kenya. I have tried to imbue my report with observations of a philosophical nature,
1087
alluding to the state of health care in my country in particular and to the state of the Third World in general. I hope that my presentation will enable you to think of Kenya like it was next door and that you will feel that our problems are your problems as well. If I succeed in this respect, the fate of my patients is bound to improve. I do thank you again for inviting me and for patiently listening to my introductory remarks. Health-or rather the lack of it-dwells at the interface of nature and culture and I felt that it is my duty to my patients and to my audience to put pediatric surgery in a wider frame than is usual at surgical gatherings. If you judge this to have been pretentious, please forgive me.