Kenyan Psychiatrist

Time to implement the health task force report

2012-02-12T11:38:00.000+03:00

By LUKOYE ATWOLI
Sunday Nation 12 February 2012

At the height of the doctors’ strike last December, sceptical observers wondered whether doctors would be willing to go back to work if nothing but their pay demands were met. The answer was not a simple yes or no.

The doctors’ main condition was that the government should show some commitment to addressing the 13 issues raised by the union in their memorandum; the matter of salary and emoluments was not even the main one.

The strike was eventually called off after the government agreed to introduce new allowances for doctors, as well as to establish a task force to address the policy issues and a negotiating team for a comprehensive collective bargaining agreement. The sceptics laughed at the “naivety” of the doctors in accepting “peanuts” and leaving the health sector in as bad a shape as it had been at the beginning.

The union leadership took this step in realisation of the fact that a doctors’ strike could not go on indefinitely, and that the biggest loser was the common mwananchi who could not access quality health care in the absence of doctors. The promise made by the union to Wanjiku was that her needs were still at the top of the agenda and that, now that we had been heard, we were ready to get to work providing solutions for the problems we had identified.

A couple of weeks ago, the task force appointed to look into health policy issues raised by the union presented its report to the permanent secretaries in the Ministries of Health. The report identifies serious gaps in the management of the health sector and provides solutions for each of the identified problems.

If the report is implemented, it is unlikely that this country will ever see another doctors’ strike in this generation. Among the issues addressed, the main one was that the ministries of Health continue to be grossly underfunded despite increasing health needs of the growing population and the growing burden of infectious and non-infectious diseases.

Other problems included inadequate infrastructure, drugs and equipment, understaffing, little investment in the training of health workers, lack of compensation for some doctors in training and the lack of a proper legislative framework for health.

Key recommendations from the task force include the allocation of a Health Stimulus Package of about Sh220 billion over the next three financial years and a commitment by government to gradually increase regular health allocation by two per cent per year until the Abuja target of 15 per cent is met.

Specific recommendations were also made for revitalisation of the health infrastructure, including the identification, equipping and staffing of county-level referral hospitals across the country. Recommendations were made on the management of the health workforce and health facilities across the country.

A major plank of the report is the formation of a Health Services Commission through a constitutional amendment to manage the human resources for health and provide guidance on health policy to the government.

This report needs to be fully implemented if we are to revolutionise Kenyan health care. Indeed, one hopes that all political parties competing in the coming General Election will take up this report and make it their health manifesto, in order to guarantee better health for all.

Only then can Kenyan doctors finally say to Wanjiku, “You were not forgotten”.

Dr Atwoli is secretary, Kenya Psychiatric Association and lecturer, Moi University School of Medicine. www.lukoyeatwoli.com

Councils of elders pose a threat to democracy

2012-02-07T17:20:00.000+03:00

By LUKOYE ATWOLI
Sunday Nation 05 February 2012

Amorphous groups calling themselves “councils of elders” habitually gain prominence in election years in Kenya. They purport to represent tribes in diverse areas of national life, and issue press statements in support of one thing or the other. This year is no different.

Last week one of these councils issued a press release on the subject of “confirmation of charges by the ICC”. The statement began by indicating that they had conducted “serious deliberations and assessment of the ruling, the issues raised, including the evidence given by all the parties concerned”. Their main concern was not the court’s ruling, but the “evidence upon which the ICC chief prosecutor Luis Moreno-Ocampo used and upon which the court based the ruling”.

The council suggested that the ICC prosecutor was “deliberately selective in deciding on those he considered as bearing the highest responsibility for the violence”. Apparently, the council knows the true causes and perpetrators of the violence, and feels that they have been deliberately ignored.

Tellingly, however, they indicate that they share the thinking of, among others, the dissenting judge Hans-Peter Kaul. This ICC judge has indicated in his numerous opinions that he believes heinous crimes were committed in Kenya, and that the accused may have had a role in the commission of those crimes.
His only gripe has been that the crimes do not meet the threshold of crimes against humanity, and should be prosecuted in Kenyan courts.

In my opinion, their claim to legitimacy aside, the council has every right to express its opinion on this case, just like any other group in Kenya. However, they can neither purport to represent a community’s thinking, nor successfully deal with the ICC through the media.

Ideally, they should have sought to be enjoined to the ICC case, and provided the evidence in their possession to the court to acquit those they consider to be wrongfully prosecuted, and nail those that are truly responsible. That they chose to address it in a newspaper advert suggests ulterior motives on their part.

The statement, however, addressed a very important outcome of the post-election violence – the issue of internally displaced persons (IDPs). No matter who was responsible for the violence, it is completely unconscionable for any national leader to sleep peacefully while innocent Kenyans continue to languish in makeshift camps across the country.

The fact that it takes a tribal council of elders to ask that the President’s orders on this matter be obeyed speaks volumes about the stability of our State. The President has issued numerous orders on the resettlement of the IDPs, but nobody seems to be paying him any heed.

Kenya has an elected government whose primary role is to ensure that the welfare of citizens is placed above all other considerations. When citizens start feeling that the elected government is unable to address their needs, and they turn to unelected “councils of elders” and vigilante groups, the integrity of the State is imperilled.

In purporting to represent whole communities, these councils invalidate the need for the democratic infrastructure we are building in our country. In my view, they are an anachronism that we ostensibly replaced with several elected individuals and institutions, and their re-emergence poses a threat to these same institutions, and to the unity and security of our country.

Dr Lukoye Atwoli is secretary, Kenya Psychiatric Association and lecturer at Moi University’s school of medicine www.lukoyeatwoli.com

Where, for God’s sake, is our moral compass?

2012-01-29T13:33:00.005+03:00

By LUKOYE ATWOLI
Sunday Nation 29 January 2012

This week, let us try and resolve the dilemma presented by the following case.

One day, a businessman is called to the office early in the morning, and finds critical parts of the building burnt to the ground. The security guards have all been killed, and several female employees have been sexually assaulted and left for the dead. The businessman is devastated, and calls in the police for investigations.

A while later, the police inform the businessman that while investigations are still on-going, his exemplary employee, an accountant with an impeccable record, has been implicated by several witnesses. Despite his reservations, the man tells the police to ensure that no stone is left unturned in investigating the incident.

At the end of investigations, the police inform him that they have sufficient evidence to recommend prosecution of the accountant and his accomplices for the heinous crimes at the business premises. They clarify to him that this does not mean that the accountant is guilty of any crime, and that this determination can only be made by a competent court of law.

They arrest the accountant and hand him over to the prosecutor, together with all the files containing the results of their investigations. The prosecutor studies the case files and agrees that there is sufficient evidence to charge the accountant with murder, arson, sexual assault, violent robbery and related crimes. He goes ahead and files the case in court.

Seeking injunction

However, before a judge is allocated to hear the case, the accountant’s lawyer goes to another court seeking an injunction against the prosecution. He argues, as we often do in Kenya, that his client’s prosecution will result in his loss of income and prestige in society, and will prevent him from getting the promotion that he has been waiting for at work.

The accountant remains a free man while all this is going on, and continues showing up at the office while the owner organises to renovate the destroyed sections of his building and hire replacement staff. The accountant’s friends approach the employer and implore him not to take any action against the accountant since he is still not guilty until a court of law proclaims otherwise.

Here is the question: If you were the business owner, what would you do?

Would you wait until the case against the accountant’s prosecution is heard and determined before you make a decision? And what would that decision be?

Alternatively, would you wait until he is charged substantively with the crime before you make a decision? Again, what would that decision be?

Finally, would you wait until he is convicted before you make up your mind on what to do with him? In your thinking process, would one of your options include hiding him in your premises should the court rule against him in any of the cases?

In simple terms, at what point would you ask him to leave and never come back?

These, in my view, are the questions Kenyans must answer about the senior government officials charged with crimes against humanity at The Hague. Everybody knows what the law says about ethics and integrity, but the answers to these questions will only be found in our personal and collective moral codes.

Spending time scouring the statutes to find any and all exculpatory provisions is very telling indeed.

Dr Lukoye Atwoli is secretary, Kenya Psychiatric Association and lecturer, Moi University School of Medicine. www.lukoyeatwoli.com

General Election after the next may be in 2018

2012-01-23T15:14:00.006+03:00

By LUKOYE ATWOLI

Sunday Nation 22 January 2012

Before the High Court ruling on the election date was made, all Kenyans were clear in their minds about when they thought the elections should be held. A school of thought held that the August date mentioned in the Constitution was sacrosanct, and there was no other sane interpretation on the matter.

Others, including some lawyers who had participated in writing the various drafts of the Constitution, held that the first elections were supposed to be held in December of this year. Many Members of Parliament were totally against the August date, and would have been happy with a date some time in mid-2013 if that were possible.

After the ruling, however, no Kenyan, with the possible exception of the President and Prime Minister, knows with any degree of certainty when our next General Election will be held. All we know is that elections shall be held between 60 days from Monday (if the Principals dissolve their coalition) and March 15, 2013.

Knowing our MPs, it is obvious that they will do all in their power to have elections on the last possible date.
It is, therefore, quite conceivable that our next elections will be held on the ides (March 15) next year. Notwithstanding the Caesarian omens associated with this date, there is one possible consequence that no one has commented upon.

Second elections

Many Kenyans assume that it is obvious that the second elections under this Constitution will be held on Tuesday, August 8, 2017, unless the Constitution is amended to change this. Unfortunately, this is not the case, even though the High Court judges suggested that, as a result of their ruling, the term for the next parliamentarians may have to be shortened.

The relevant constitutional provisions indicate that General Election “shall be held on the second Tuesday of August in every fifth year.” Now if the next General Election is held on any date in 2013, it follows that the fifth year after 2013 would be 2018. It follows, therefore, that the elections after the next would be held on Tuesday, August 14, 2018, effectively lengthening the term of the next Parliament by anything from five to eight months.

Have any of the protagonists thought about this? One should not be surprised if some MPs have thought about it and are secretly hoping that they will be among the chosen few who will enjoy two prolonged terms in Parliament.

It is possible then that, as we continue arguing about when the next elections should be held, we may just be pushing the problem to the next generation of voters.

A curious point in all this debate is the dogged determination with which the minister for Justice is pursuing a Constitutional amendment to fix the General Election date in December. Though the reasons being given for this are temporary, the effects of such a date change would be permanent, fixing all future elections in December.

Does this mean that a future crisis will result in the government of the day seeking another amendment to change the election date?

My advice to the minister is to just leave well alone, and let the Principals decide.

A more useful, non-contentious First Amendment, in my view, should be the one to entrench a Health Services Commission in the Constitution.

Dr Lukoye Atwoli is the secretary, Kenya Psychiatric Association, and lecturer at Moi University’s school of medicine
www.lukoyeatwoli.com

Caution Needed With the Government Health Plan

2012-01-16T15:15:00.000+03:00

Lukoye Atwoli

Sunday Nation 15 January 2012

The government recently announced a new health plan for civil servants encompassing outpatient and inpatient care as well as payments for disability and death. There has been scanty information on the administration of the scheme, but it seems clear that it would be administered largely by the National Hospital Insurance Fund (NHIF).

On the face of it, this deal is good for civil servants, as it offers them something they have needed for many years. The workforce in Kenya remains largely poor and unhealthy, compromising the quality of work in the civil service and creating a vicious cycle that ensures that majority of Kenyans remain mired in poverty with no hope for a respite.

This deal has the potential of alleviating this problem and improving the health of Kenyan workers.
Improved health care will obviously have a huge impact on the economy and should see us getting closer to achieving our national goals and vision.

The problem arises when one attempts to interrogate the implementation of this plan.

NHIF indicated that civil servants would be able to get care at all public and mission facilities and some private hospitals that will be accredited for this purpose. Indeed, workers were advised to nominate three facilities they would be seeking care at under the plan.

After the announcement that the plan was operational from the beginning of the year, some disturbing issues have been noted by concerned civil servants. NHIF has allocated every civil servant to particular health facilities, both public and private.

Under the plan, NHIF has identified some private "providers" to provide care for civil servants.
In an ideal situation, one would have expected NHIF to sign contracts with the individual hospitals to offer care to the covered members, but instead they have contracted what are effectively middlemen to administer the plan in some areas.

Two of the contracted private providers do not have sufficient facilities of their own, and it is clear that they will only serve as middlemen in the process. Some of the "clinics" identified on their websites are actually non-existent, and it is even doubtful if they have enough workers to offer quality health care to members of Kenya's civil service.

There are two major problems with this arrangement.

Firstly, there have been queries raised in the past over NHIF's ability to manage the funds they currently collect for outpatient cover. One wonders what has changed since an audit revealed that a huge proportion of funds collected by NHIF is used for administrative purposes, and not the core business of providing health insurance.

Secondly, the details of the scheme remain hidden, even to the beneficiaries themselves.
Many civil servants currently do not know anything about it except what has been covered in the media.
Is this the way to implement a medical scheme? Where are the individual contracts for the civil servants, containing the extent and limits of their cover?

For instance, where will they be treated when they get sick away from their stations?
In my view, services at our public facilities need to be improved to enable all public servants to have access to care anywhere in the country.

NHIF should then have no problems providing cover for these individuals, and no public servant should ever have to seek care in a private facility.

Dr Lukoye Atwoli s secretary, Kenya Psychiatric Association and lecturer at Moi University's school of medicine.

Health care as a campaign issue this year

2012-01-10T10:04:00.004+03:00

By LUKOYE ATWOLI
Sunday Nation 08 January 2012

In typical Kenyan fashion, this late into the election season, no political party or presidential candidate has come out with a coherent governance strategy for the next government should they win political power. In an ideal situation, political parties and candidates would by this time have clear positions on key areas of the economy, including employment, education, taxation, infrastructure, security and health. Elections would be won or lost on policy issues, rather than the language spoken in a candidate’s home.

Our Constitution has attempted to cure this malady that afflicts our entire body politic, but because the players remain largely unchanged, key provisions risk being ignored or violated outright. As long as the citizen remains quiet and plays along with the political games of musical chairs, little is set to change.

By this time in the campaign, all candidates should have in place teams that will handle every aspect of their campaigns. They should have experts directing key campaign policy areas, with the expectation that should they win, the experts would take on the roles of Cabinet secretaries and other key policy positions in the new government.

Voters will then have adequate time to scrutinise the candidates, their potential Cabinet secretaries, and their policies in different areas of national life. These teams should in fact be the determining factor as far as the fate of the candidate is concerned.

Since no candidate has as yet come up with a health blueprint for Kenya, today I will take the liberty of suggesting some campaign issues in this area.

It is no secret that our health care system is in crisis. Despite attempts at reform over the past 20 years or so, inadequate funding and lack of political will have conspired to ensure progress is painfully slow and hard fought. A dramatic demonstration of this crisis is the fact that the portion of the budget allocated to the health sector has been shrinking progressively in recent years, and currently hovers at around 5 per cent of the national budget.

A health campaign platform should focus on making the following commitments.

Firstly, the entrenchment of a Health Service Commission in the Constitution is necessary to have a more orderly management of the human resources for health. A possible constitutional amendment Bill has already been drafted, and all the candidate needs to do is pick this and run with it in order to gain the support of Kenyans who care about their health.

Secondly, candidates must commit to increase government health expenditure to at least 15 per cent of the national expenditure to finance the necessary reforms in the sector. This was in fact agreed upon by our government years ago in Abuja, but has never been implemented.

Thirdly, they must commit to establish and properly equip and staff 47 county referral hospitals across the country, to more effectively offer services to all Kenyans in an equitable fashion as demanded by our Constitution. These hospitals will be the benchmarks against which facilities higher up or farther down the referral chain will be measured in terms of funding, staffing and equipment.

These commitments have the potential to positively change the lives of all Kenyans. Are our politicians willing to discard old tribal habits and take on issue-based politics this year? Only time will tell.

Dr Lukoye Atwoli is secretary, Kenya Psychiatric Association and lecturer at Moi University’s school of medicine www.lukoyeatwoli.com

New Year Provides Opportunity for Real Change

2012-01-04T14:12:00.000+03:00

Lukoye Atwoli
Sunday Nation 01 January 2012

Hopefully Kenyans have enjoyed their holidays and are now looking forward to a successful new year. Having ended the past year on an uncertain note, one can only hope that 2012 will be a year of answers for our country. However, we start the new year with a couple of heavy questions weighing on our collective minds.

The first question regards the fate of the Kenyans facing cases at the International Criminal Court (ICC). Will anyone be found to have a case to answer? And if this happens, will it spell the end of the era for ethno-political impunity? Obviously, we have invested a lot of emotional energy in the ICC process, and it actually seems as though everything has come to a standstill until the cases are determined.

The result is that expectations are very high that the ruling on these cases will help shape the behaviour of politicians and their supporters during campaigns. While there is no telling how the ICC ruling will go, one can predict with relative certainty that its effect on our political behaviour will be minimal.

Despite claims that Kenyans have changed as a result of a string of political tragedies since independence, there is as yet no objective evidence to bear this out. We still remain tribal in our voting patterns, and worse, we treat elections like a war in which our opponents become mortal enemies, fit to be hanged, drawn and quartered.

Political maturity

This mindset will have to change if we are to attain political maturity in this generation.
The second question we shall grapple with this year is whether we shall have elections in August, December, or at all! As we await the court ruling on this matter, the controversy surrounding the election date serves to remind us never to take anything for granted, including matters about which we think the law is categorical.

As far as the elections date is concerned, we know that politicians are simply angling for an extended period of earnings, knowing as they do that most of them will not be returned to leadership at the next general election. Further, those that will be returned will probably earn significantly less than current parliamentarians, if we are to believe the noises coming from the Salaries and Remuneration Commission.

In the midst of all this pessimism and uncertainty, there is still reason to hope that 2012 will be the year for Kenyans to triumph. This year, we have the opportunity to finally banish the reign of kleptomaniac sociopaths and establish a just, responsive government in their place. The first steps are evident in our continued trust in the sanctity of our Constitution, and we must be ready to defend it with all our resources.

In my opinion, we were going about re-engineering our society the wrong way until we stumbled upon constitutional reform. Our Constitution provides us with our best opportunity yet to set up institutions that will determine the shape of our country in the years to come. With these institutions in place, we shall not have to exhort people to vote for "development conscious" leaders, or to avoid tribal considerations in making electoral decisions.

No matter who gets elected to positions of leadership, the integrity of the State must remain insulated from the mischief of politicians.

Dr Lukoye Atwoli is the secretary, Kenya Psychiatric Association, and lecturer at Moi University's School of Medicine. www.lukoyeatwoli.com

HAPPY NEW YEAR!

2012-01-04T14:09:00.000+03:00

Happy new year, dear readers. Due to vacation and travel, we were unable to post any stories between Christmas and the New Year.
Hopefully we have our reading gear on, given that this year promises to provide a lot more fodder for pundits than any in the recent past.
To make up for our transgressions, we are posting the two Sunday Nation articles that appeared on Christmas Day and New Year's Day, and we welcome comments and suggestions of material we should cover this year.
Let's get on with it!

We Need More Vigilance to Have Our Way in 2012

2012-01-04T12:41:00.000+03:00

Lukoye Atwoli
Sunday Nation 25 December 2011

At the beginning of this year, I shared in this column some of my hopes and wishes for Kenya. To illustrate just how much we remain in the same place despite the illusion of progress, let us review the extent to which these wishes were actualised in 2011.

The first wish was that the International Criminal Court (ICC) would finally make a decision on the culpability of the so-called Ocampo Six. As we enter the fifth year since the last General Election and the ensuing madness, we are still in the dark about the strength of the ICC prosecutor's case against these Kenyans. A ruling is set to be made early next month, and one hopes it will help to bring closure to this matter as we face an even more complex General Election.

The coming election is fraught with many uncertainties, with the electoral commission chairman vacillating between the possibility of an August date and a December date, while politicians are angling for an even later date some time in 2013. The High Court is expected to rule on this issue next month, and we can only hope that the ruling will conform to the letter and spirit of the Constitution and will not bend to the whims of our political class.

The second wish concerned the operationalisation of the Constitution through legislative action. Although Parliament literally rushed to beat constitutional deadlines mid this year, a lot still remains to be done.

Little more seriously

Some laws passed in the rush were later discovered to have errors that would have been corrected had Parliament taken its job a little more seriously.

The third concern raised was that the hullaballoo about electoral boundaries had gone on for too long, and it was hoped that the matter would be resolved within the first few months of this year. Sadly, the Independent Electoral and Boundaries Commission (IEBC) has only recently been constituted, and the chairman has promised a report on new boundaries early next year. Given that it will be an election year, it is obvious that politicians will be at it again, fighting for turf as if they will hold their political posts all their lives.

Of all the wishes I had at the beginning of the year, only the fourth and final one was achieved. The government did not make any moves to implement the idea emanating from a section of Parliament that Kenya withdraws from the Rome Treaty and disengages from the ICC process.

However, in the course of the year, after a Kenyan court issued an arrest warrant for the President of Sudan on behalf of the ICC, the government went into a frenzy, accusing the courts of ignoring geo-political realities in their work. This probably played a role in the decision by the ICC to refer Kenya and some other African states to the United Nations Security Council and the Assembly of State Parties for possible sanctions.

In summary, despite some gains accruing from the enactment of a new Constitution, for many of our politicians, it is still business as usual. Unless we resolve to keep our leaders under an intense spotlight, all we have gained over the years will be lost to a political class that is completely out of touch with the strivings of the man on the street.

Dr Lukoye Atwoli is secretary, Kenya Psychiatric Association, and lecturer, Moi University School of Medicine. www.lukoyeatwoli.com

Doctors' Strike Exposed Rot in the Health Sector

2011-12-23T09:30:00.003+03:00

Lukoye Atwoli
18 December 2011

The Kenya Medical Practitioners, Pharmacists and Dentists Union called off the doctors' strike on Wednesday last week after some confusion on Tuesday about whether the strike was on or off. This was done after the union membership was convinced that the interests of the common citizen had been addressed, among other things. Today, it is important to reflect upon the effects of this strike.

For the first time in the history of this country, a trade union organised a strike largely with public interest at the core of it. Among the demands the doctors' union had, the most prominent included construction of more health facilities, equipping existing facilities, training and hiring of more health workers and increasing government spending on health.

The union called off the strike after the government admitted that things were not right in the health sector and made commitments to address the concerns raised by the union. Apart from committing to improve the pay of doctors and other health workers, the government agreed to form a joint task force with the union to deliberate on the way forward in addressing the medium and long-term issues raised by the union.

Quite apart from the fact that the government agreed to work with the doctors' union to improve the health sector in our country, the strike also achieved important milestones.

Importantly, the doctors' strike exposed the rot that exists in the health sector. Many Kenyans did not know that government expenditure on health as a proportion of total spending had been declining over the years. This has been happening despite our commitment to the Abuja Declaration that bound governments to ensure that health sector expenditure be raised to 15 per cent of that total government expenditure.

The result of declining health funding has been enormous. Health facilities have remained few and far between, and those that are available have had neither adequate staffing nor appropriate equipment to carry out basic functions of a health facility. There have also been difficulties recruiting and retaining qualified manpower, with the result that some critical health programmes in the country are solely dependent on donor funding.

The doctors' strike also exposed the dearth of leadership in the ministries of health. Throughout the crisis, both ministers were conspicuously absent. Conveniently, it was reported that they had gone abroad for treatment. How ironic that on the eve of the doctors' strike, those that were supposed to deal with it needed to seek the services of doctors outside the country!

Their absence, as well as the bungling display by the assistant minister and permanent secretary in the ministry of Medical Services, raised serious questions. By failing to provide leadership during these critical moments, the ministers might have been communicating to government that they agree with the doctors' union that there is a problem in the health sector but had no power to deal with the issues raised.

Indeed, a few days before the strike, the minister for medical services had indicated in a newspaper column that there were forces beyond his control that were determined that he does not achieve much in his docket. That it took the Treasury's intervention to end the strike may bear out this claim.

It is irresponsible to play politics with the lives of Kenyans, and the principals must act with speed to end this charade.

Dr Lukoye Atwoli is secretary, Kenya Psychiatric Association and lecturer, Moi University School of Medicine www.lukoyeatwoli.com

Doctors chose the lesser evil by downing tools

2011-12-11T11:28:00.001+03:00

By LUKOYE ATWOLI
Sunday Nation 11 December 2011

Last Monday doctors in the public service went on strike. Among the issues raised by the Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU) were inadequate staffing, absence of a scheme of service, stoppage of training sponsorships, poor working conditions and inadequate remuneration.

At the onset of the strike, fears were expressed that it would result in needless loss of lives, and it was suggested that it would be unethical for medical personnel to go on strike and leave patients to die. The Hippocratic Oath, which exhorts doctors to put their patients’ needs above all considerations, was cited as a good reason for doctors to call off their strike.

An objective observer would actually be horrified that doctors downed their tools and left their patients to their own devices. However, in order to understand why this happened, it is necessary to examine the events leading up to this strike.

Firstly, it must be appreciated that this is not the first time doctors are going on strike in Kenya or elsewhere.
This is the fourth doctors’ strike in Kenya, and the last one happened in the 1990s, resulting in a massive exodus of doctors to Europe, the United States and southern Africa. The reason for the exodus was that the government totally ignored the doctors’ demands, and instead opted to intimidate those that participated in the strike.

Everything possible

Secondly, one needs to understand the working conditions that the doctors are asking to be improved. When a doctor tells a patient or their relative that everything possible is being done to help them, it is often an intricate public relations exercise meant to hide the deficiencies in the system.

The health system in our country is rotten. Over the years, government expenditure on health as a proportion of total expenditure has progressively fallen, despite a commitment to the Abuja Declaration decreeing that 15 per cent of the budget must be spent on healthcare. The result of this neglect is self evident.

Health facilities are still few and far between, and many people have difficulty gaining access to quality healthcare within a few kilometres of their residence. Those that are available are grossly undermanned, and there are health facilities where one person performs the work of all cadres of healthcare workers. This person is often the only one available to diagnose illnesses, to dispense the treatment, to perform nursing duties and to keep the facility clean and habitable.

Supplies to health facilities have remained erratic and often do not meet the needs of the served population.
Health workers in these facilities are poorly remunerated, and it is often viewed as a punishment to be posted to remote areas of the republic because, among other difficulties, one’s housing allowance is reduced significantly outside the capital city.

In many hospitals, including the national referral facilities, needless loss of lives has been going on for a long time, and doctors are often bystanders who know what needs to be done but have no tools with which to deal with the problem.

The ethical dilemma that faced many doctors at the beginning of the strike was really a no-brainer. What is more ethical: to acquiesce to the continued loss of lives in an underfunded system or to walk away from it all and let everyone know that all is not well?

The striking doctors chose the latter.

Dr Lukoye Atwoli is secretary, Kenya Psychiatric Association, and lecturer, Moi University School of Medicine. www.lukoyeatwoli.com

Ombija’s ruling exposes hypocrisy of our leaders

2011-12-05T18:22:00.001+03:00

By LUKOYE ATWOLI
Sunday Nation 04 December 2011

In a week that saw the former President of Cote d’Ivoire shipped off to the International Criminal Court (ICC) to answer charges of crimes against humanity, including murder and rape, the High Court in Nairobi made a ruling that sent shockwaves across the region. Judge Nicholas Ombija ruled that Sudan’s President Omar Hassan Al-Bashir should be arrested and handed over to the ICC should he ever set foot in Kenya again.

The ruling has clearly ruffled many feathers, if the robust response by our government and regional bodies is anything to go by. Many have accused the judge of ignoring regional concerns, and some have even accused him of serving “foreign” masters.

Regional repercussions

The executive arm of the government has vowed to appeal against the ruling, and has suggested that the judiciary needs to be mindful of the regional repercussions of its activities. From my point of view, it is very clear that the Sudan is a very important component in the regional peace and development efforts under the auspices of Igad.

It is also clear that any disagreement with Sudan would be very inconvenient for Kenya especially as we pursue terrorists into the heart of Somalia.The crisis does not augur well for a country that aspires to brand itself as a neutral arbiter for peace in the region.

Apoplectic response

All this is true and may, to a large extent, justify the government’s apoplectic response to the warrant of arrest for President Al-Bashir.

There is only one small problem, I am afraid. The law, as they say, is an ass, and justice is meant to be blind!

Just over a year ago we passed a Constitution to replace the older document that had over several decades been reduced to an autocrat’s charter. Among other provisions, our Constitution today provides that “the general rules of international law shall form part of the law of Kenya”, and that “any treaty or convention ratified by Kenya shall form part of the law of Kenya under this Constitution”.

Article 3 (1) further places upon all persons the “obligation to respect, uphold and defend this Constitution”.
After the passage of the Constitution, our Parliament went a step further and enacted the International Crimes Act that, in practice, domesticates the provisions of the Rome Statute. Attempts by a section of parliamentarians to get the government to pull out of the treaty that established the ICC were ignored by the executive.

Finally, the government is on record indicating that we are cooperating with the ICC and shall continue to do so in the matter of post-election violence where several prominent Kenyan politicians are among the suspects.

A disinterested observer, such as a judge might be, would be left in no doubt that the government is very serious in its commitments to the Rome Statute, and would expect therefore that any legitimate requests emanating from the Hague would be implemented by all arms of the government as required by our Constitution and local and international statutes.

Rome Statute

The High Court ruling exposes the hypocrisy of our leaders who make laws they do not intend to implement.
As long as we remain signatories to the Rome Statute and retain the International Crimes Act, any other judge worth his salt would rule exactly as Mr Justice Ombija did.

Dr Lukoye Atwoli is the secretary, Kenya Psychiatric Association and lecturer, Moi University’s school of medicine www.lukoyeatwoli.com

The key steps in a review of health legislation

2011-11-28T16:19:00.001+03:00

By LUKOYE ATWOLI
SN 27 November 2011

As the ministries of Health grapple with the enormous task of reviewing all health legislation in line with constitutional requirements, certain steps are necessary to ensure the product of this exercise meets the stated objectives.

The first step in this process should involve a review of all existing legislation on health, as well as all the enabling executive orders that have had a bearing on health in Kenya. This audit will reveal the true scope of the problem, including the existence of some archaic health legislation dating back to the colonial days, side-by-side with modern laws and regulations.

In my view, input from legal experts will be required for this process to be done successfully. Doctors and other Afya House technocrats may not be able to conduct the legislative audit efficiently simply because they are not trained for it.

The second step in this process will be to identify the constitutional provisions relating to health.These include provisions for the right to health, emergency care, clean environment, dignity and so on and so forth. This will provide Afya House with the scope of the problem as far as harmonising existing legislation with the Constitution is concerned.

Such a review may reveal that some of the health laws need to be repealed, and new Acts of Parliament will have to be drafted in order to address issues that had not been addressed under the previous constitutional regime.

In my opinion, once these reviews have been done, it will then be necessary for the government to develop a national health policy that is in line with the constitution, in order to provide a framework for the enactment of the necessary legislation. Given that a policy framework already exists in the health sector, tweaking it to redirect it towards constitutional requirements should not be difficult.

Once the policy has been reviewed and redirected, a few laws will have to be written to implement the policy directives and ensure full compliance with the constitution. In my view, such laws must include provision for a health services commission to coordinate the deployment and remuneration of all health workers in the public service.

Although it had earlier been suggested that this commission be provided for in the constitution, this commission was ignored probably due to the docility of the health workforce in this country. The situation may, however, be remedied by an Act of Parliament.

The second provision that the proposed health law must include is a health professionals’ council which will help craft the definitions of the various health professionals. It will provide benchmarks to be fulfilled for one to be considered a medical doctor, nurse, clinical officer, nutritionist or physiotherapist, among other health professionals. Apart from regulating ethical practice in the health professions, the council will also help clarify constitutional terms such as health, abortion and emergency care.

Finally, we must ensure that the process of making the proposed health law is fully participatory, and the health ministries must initiate a consultative process both within and without the health sector. They should also ensure that the concerns of health workers through their professional associations and unions are addressed in the new law.

These are the minimum requirements that will ensure that the health of Kenyans is in safe hands under the new dispensation.

Dr Lukoye Atwoli is the secretary, Kenya Psychiatric Association, and lecturer at Moi University’s School of Medicine www.lukoyeatwoli.com

Government should not use war as a stock excuse

2011-11-20T17:27:00.001+03:00

By LUKOYE ATWOLI

Sunday Nation 20 November 2011

Lecturers went on strike on November 9 after a two-year wait for negotiations with government bore no fruit. It is claimed that a circular from the head of the civil service advised all public service employers that there should be no negotiations until the Salaries and Remuneration Commission was in place.

Even after that purported circular was released, teachers threatened industrial unrest, and their demands were met with alacrity. Money was also allocated for police and military salaries and allowances after some low-level grumbling and veiled threats to national security. More recently, money has been found to address problems at the two national referral hospitals, after work stoppages at both institutions threatened to get out of hand.

The message that is coming out of these events is that it is pointless to engage the government in civilised conversation when it comes to improvement in terms and conditions of work in the public service. Apparently the only language top government officials understand is of unrest and strikes.

Indeed, preparations are under way for a nationwide strike by doctors and other health workers in the public service over poor pay, unhealthy working conditions and uncertain career progression. The government is aware of the preparations, but has kept mum, waiting for the crisis to explode so it takes action.

Lately, senior government officials have taken to asking workers to be patriotic, suggesting that all government resources have been diverted to the war in Somalia against the Al-Shabaab. The PM practically accused striking lecturers of being unpatriotic by creating a second “war front” at a time when the country is at war.

This accusation has been repeated by the minister for Higher Education and her assistant, both former lecturers, who would be expected to be more sensitive to their colleagues’ demands. It seems, therefore, that the government has decided the stock response to any salary demands will feature the war in Somalia and appeals for patriotism. This implies the war was impulsive and unplanned, and that necessary resources were not set aside for the war in order to allow the rest of the economy to function normally.

If this is true, then it is clear that we are being led by government devoid of any sense of direction, and we are in real trouble. A more plausible explanation is that the war is being used to hoodwink Kenyans about the true cause of financial haemorrhage in this country.

Kenya experiences economic difficulties towards an election year, as politicians engage in schemes to raise campaign funds. It is not inconceivable that massive looting is going on on both sides of the grand coalition, and that we shall only be able to appreciate the scale of the looting after the General Election next year.

The PM repeatedly reminds us that it is possible to chew gum and climb stairs at the same time. Is he now suggesting that this is no longer the case?

Dr Lukoye Atwoli is secretary, Kenya Psychiatric Association and lecturer at Moi University’s School of Medicine www.lukoyeatwoli.com

Finally, tribe is king in the Kenyan public service

2011-11-13T11:16:00.001+03:00

By Lukoye Atwoli
Sunday Nation 13 November 2011

Last Wednesday, a parliamentary committee made a decision that should have wide-ranging repercussions across the governance structures in this country. The parliamentary Labour and Social Welfare Committee reportedly rejected the nomination of Ms Winfred Lichuma to be the chair of the National Gender and Equality Commission, and questioned the grounds on which the selection panel overlooked three others in making their choice.

Apparently, the panel rejected the top three contenders on the grounds that their nomination would skew the ethnic composition of the commission and other government organs, and run afoul of the constitutional requirement for ethnic balance in state institutions.

A point of concern was that their ethnicity was determined by others, and none of them was asked about their tribe during the interviews. For instance, it was assumed that Prof Maria Nzomo was Kikuyu despite having a mother she considers to be Kikuyu and a father she considers to be Kamba. To further muddy the waters, she is married to a person considered to be Luhya.

Another candidate, Dr Jane Dwasi, was rejected allegedly because despite having Luhya parentage, her father had moved to “Luoland” and she now “prefers to be identified as a Luo”. The selection panel allegedly decided not to nominate her on the grounds that another of her “tribesmates” had already been appointed to a senior post in another constitutional commission.

Serious concerns

Two serious concerns emerge in this case. The first regards the injustice of allowing others to define an individual’s ethnicity using some vague criteria.

The examples of Prof Nzomo and Dr Dwasi demonstrate the difficulty inherent in using a vague social attribute to make decisions that have a bearing on people’s lives and the opportunities available to them. For no fault of their own, and in spite of their obvious qualifications, they were stood over because it was thought that their brilliance was subordinate to the tribe they were boxed into by some government functionary which, in any case, turned out to be inaccurate.

Ethnicity is a very complicated social construct, and must be approached with great care. For instance, a European student of mine was scandalised to learn that children whose parents hailed from different ethnic communities were considered to belong to their father’s tribe. She felt that the only thing the children shared with their father’s tribe was the language. Their personalities and values were so heavily influenced by their mother that they should, for all intents and purposes, be considered to share her ethnicity.

The second concern is the relevance of tribe in national decision-making. In a functioning meritocracy, people take credit for their own success, and accept responsibility for their failures without excuses. In Kenya, it seems we are moving towards a system where the fortunes of our tribesmates will determine how far we go in securing public office.

If one intends to apply for a senior post in government, they must make sure that none of their tribesmates apply for the same job. They must further ensure that they find a way of flaunting their ethnicity in a way that is obvious to the interviewers, so that qualifications become secondary to that ethnic expression.

Tribe has finally become the key qualification for positions in the public service.

Dr Lukoye Atwoli is secretary, Kenya Psychiatric Association and lecturer, Moi University’s school of medicine
www.lukoyeatwoli.com

Elections can be held any time during 2012

2011-11-06T11:32:00.001+03:00

By LUKOYE ATWOLI

Sunday Nation 06 November 2011

Last week, the chair of the Interim Independent Electoral Commission, while being interviewed for the same post in the successor electoral body, asserted that “it will be impossible to hold elections in August 2012”. He went ahead and recycled the same arguments that have been presented in the past by the government, including the budgetary cycle, time for preparations, voter education and others in a similar vein.

As a layperson, I must admit that my reading of the law is usually very plain, and devoid of the refined nuances that I suspect are imparted in law schools all over the world. However, my understanding of the law is that everyone must strive to know it, and try to understand the implications. Indeed, the lawyers will be the first ones to tell us that ignorance of the law is not a legitimate defence.

It is in this spirit that I would politely beg to differ with the IIEC chairman. Making an assertion such as the one he made during the interview is dangerous, and indicates that Kenya is already facing a constitutional crisis.

Under the constitution and the laws of the land, it is a basic assumption that elections can be held at any time whenever necessitated by happenings in the political arena. Indeed, the IIEC has successfully carried out several by-elections and a referendum, without telling us that it is impossible to fulfil its mandate.

Ten months

Coming out 10 months before the scheduled date of elections to tell us that it is “impossible” to plan and organise elections on time is an admission of serious lack of foresight, and brings into question the competence of the chairman and his team.

Since it is clear that the IIEC and the government have identified possible bottlenecks that will make it difficult to hold a General Election in August next year, why have they not set in motion strategies to eliminate the constraints?

Why did the IIEC not include budget estimates for the next elections in the last budget? Why have they not begun voter education both locally and in the diaspora? Why have they not begun recruiting the manpower needed for elections in August, and identifying suppliers who may be approached for various services related to the elections?

If the IIEC and government have not started addressing these issues with the seriousness they deserve, one can only read a conspiracy to make it “impossible” to hold elections when they are due in order to facilitate some obscure agenda.

If, on the other hand, steps are already being taken to ensure that these problems are addressed, why is the IIEC chair supporting claims that elections cannot be held on schedule next year?

Further insight may be gained by reading Part 3 of the Sixth Schedule of the Constitution. Section 9(2) of this schedule clearly anticipates the possibility that the coalition established under the National Accord may be dissolved even before 2012, resulting in a General Election as provided for under the Constitution.

Reading this section, and of course keeping in mind that nature has its own designs on our lives, what would the IIEC (or its successor) do in case vacancies arise in all elective posts in the republic before August next year? Will they just wring their hands and proclaim their impotence?

I don’t think so.

Dr Lukoye Atwoli is secretary, Kenya Psychiatric Association and Lecturer, Moi University School of Medicine www.lukoyeatwoli.com

Government responsible for deaths at Moi hospital

2011-11-03T09:46:00.000+03:00

Sorry for the delayed posting of last Sunday's article. Here goes!

By LUKOYE ATWOLI

Sunday Nation 30 October 2011

Last week the Moi Teaching and Referral Hospital in Eldoret was virtually closed down due to a shortage of essential supplies that would allow it to function as a referral hospital. Specialists at the hospital concluded that the hospital could hardly operate at the level of a sub-district hospital, and stopped offering all specialist clinical services as a result.

The hospital’s Intensive Care Unit had long ceased to function after all the machines broke down, and the theatre was closed due to lack of essential supplies to ensure that patients could get safe surgery at the facility. The few emergency cases that were attended to before the theatre was closed had poor outcomes as a result of lack of sterilising supplies and antibiotics to prevent infections.

In the rest of the hospital, lack of bare essentials such as medicines, gloves, syringes and needles, and stationery, together with a demotivated workforce combined to make a patient’s stay at the hospital a living nightmare. Doctors at the hospital agreed that the ethical thing to do was to refer patients to safer facilities, and advise colleagues not to refer their clients to the second largest referral hospital in Kenya.

The government response was typical. A new acting director was appointed, and promises were made about funds being made available to address the hole in the hospital’s budget. Supportive noises were made by politicians, and a turf war even erupted when the vice-president visited the facility on Sunday.

On the same day the VP visited the hospital, a patient died at the private wing of the hospital due to anaemia. Although her relatives and well-wishers were willing and ready to donate blood to save her life, the hospital and the regional blood transfusion centre did not have blood screening kits to ensure the safety of the product. Many patients died, and continue to die, of easily treatable conditions due to lack of cheap antibiotics in the wards.

Health workers in the hospital have been exposed to grave risks due to a shortage of protective gear while handling highly infectious material.

It is time someone took direct responsibility for this state of affairs. Several individuals must sleep with these preventable deaths on their conscience.

The hospital management should not have allowed the situation to deteriorate to this level. If necessary, they should have left their posts and gone back to the wards if they felt that the government was prepared to let patients die for whatever reason.

The hospital management board cannot escape responsibility by pretending that the situation deteriorated suddenly without their knowledge. If the board was unaware about the true financial position of the hospital, then the whole lot of them should bear responsibility for the preventable deaths.

The minister for Medical Services, under whose docket the hospital falls, was aware of the financial problems at the hospital long before the crisis exploded into the national limelight. He must not be allowed to have one more peaceful night’s sleep until he exorcises the ghosts of the innocent patients who died, and continue to die unnecessarily under his watch.

Above all, President Kibaki and Prime Minister Raila Odinga must be held to account. The blood of these innocent Kenyans is on the collective head of these two men and their “nusu mkate (half a loaf)” Cabinet.

Dr Atwoli is secretary, Kenya Psychiatric Association, and lecturer at Moi University’s School of Medicine www.lukoyeatwoli.com

War in Somalia: Clear objectives needed

2011-10-23T11:56:00.000+03:00

By LUKOYE ATWOLI

Sunday Nation 23 October 2011

Last week, we declared war on the al Shabaab militia that was accused by our government of masterminding kidnappings and attacks on targets within our territory. A declaration of war is not a light thing, and certain procedures needed to be followed.

Since we were committing our military and economic resources to the objective of eliminating the terror threat to our country, one would have expected the commander-in-chief of the Kenya Defence Forces address the nation, laying out the reasons for the declaration of war, the objectives of the war, and how we will know when we have achieved those objectives.

Instead, we got a press statement from the ministers for Defence and Internal Security. To their credit, the ministers outlined a cogent case for a war, enumerating the long chain of events that eventually led to the decision to attack al Shabaab deep within Somali territory. From their presentation, it is clear that the war is fully justified. What is not clear, however, is the objective of the war.

“Pursuing the terrorists wherever they may be” makes a good soundbite, but it provides very little information on the specific objectives of the conflict. A second bit of information that was missing from the statement concerned the end-point and exit strategy. Citizens do not expect to get fine details of the campaign, understanding that secrecy is part of military strategy.

Broad goals

However, broad goals of a conflict must be enumerated in order to help Kenyans to track the progress of our forces, and know when the time comes to pull out and let others continue with the war. This information needs to be provided by the commander-in-chief, who was technically given that responsibility by the Kenyan voter.

HG Wells, writing in “Outline of History”, says that “war is a horrible thing, and constantly more horrible and dreadful, so that unless it is ended it will certainly end human society”. It is for this reason that a nation must not contemplate the decision to go to war lightly, and when it does, the strategy, objectives and end-points must be very clear both to the soldiers and to the general population.

In our case, those of us that support this action can imagine one main short-term objective for this war, with a related secondary objective riding on it.

The main short-term objective, in my view, should be to create a buffer zone between Kenya and Somalia.
This zone should be heavily policed to ensure that no militiamen enter our country to terrorise Kenyans with impunity.

The secondary aim of this incursion into Somalia should be to use the buffer zone to enable the transfer of the refugee camps in the North-Eastern region of our country to Somalia. Creating a secure buffer zone will provide an environment that will allow the international humanitarian community to operate within Somalia, and free Kenya of the risks and responsibilities inherent in hosting a refugee population containing potential terrorist militia.

In the long run, it will then fall on the international community to provide support for the refugees nearer to their homes within Somalia, making it easier to re-integrate them into normal life when the situation improves in the rest of their country.

However, whatever the reasons for this war, we must continue to support our soldiers as they engage this amorphous enemy, and wish them quick success.

Dr Lukoye Atwoli is secretary, Kenya Psychiatric Association and lecturer at Moi University’s School of Medicine. www.lukoyeatwoli.com

Mental Health: Well done, but we can do better

2011-10-16T12:17:00.000+03:00

By LUKOYE ATWOLI
Sunday Nation 16 October 2011

Last week on Monday I attended the World Mental Health Day commemoration at Mathari Hospital together with colleagues from all over the country. Workers of all cadres at the hospital put up quite a show, and included both the patients and the neighbouring community in the organisation of the event. The minister for Medical Services graced the occasion, despite having just arrived in the country from an official trip to India.

During the event, guests were conducted on a guided tour of the hospital, and one could not help but notice the great enthusiasm with which the management and board of the hospital are going about improving facilities and services at the hospital. Many of the wards were under renovation, the grounds were neatly kept, and the staff appeared to have some intrinsic motivation as they went about their duties.

All these are commendable achievements in the wake of international media revelations of patient abuse and inadequate services to clients at the only national referral hospital for mental health in the country. It is difficult to blame the staff who are doing the best they can under the most difficult of circumstances to serve the most neglected segment of our society.

It is, however, important to note that whatever little has been achieved by this facility has been done under the most formidable odds possible. The national hospital operates with the budget of a district (or sub-county) hospital, and is graded as Level 4 as far as allocation of resources is concerned. The buildings being spruced up at the facility were built in the early 20th century, and most cannot be certified for human habitation if they are properly inspected.

Indeed, the hospital board seems to have realised just this, and during our visit to the hospital they presented to the minister and Afya House officials a blueprint for a new hospital to serve as the national referral facility for mental health.

This, in my view is the crux of the matter. The minister promised to do all in his power to ensure that the master-plan was implemented, and undertook to present a Cabinet briefing to his colleagues to initiate the sourcing of funds to make it a reality. He also promised to advocate for increased allocation to the hospital, and to mental health services in general, to better address the mental health of our nation.

In my opinion, we must hold the minister, and by extension the entire government, to account over this promise. We must interrogate the government’s spending priorities to ensure that mental health is included at all levels of health expenditure, and that mental health programmes are designed and implemented all over the country.

We must do these things not because any particular individual stands to benefit from the resultant improvements, but because it is the right thing to do.

Better funding

We must insist on better funding for mental health and health programmes because no nation in the whole world has ever prospered without ensuring that the whole population has access to the highest quality of health care services available within its borders.

We must recognise that failure to improve our mental health services guarantees several generations of mediocre leadership and under-achieving technocrats, leading to continued retrogression and needless suffering.

Dr Lukoye Atwoli is the secretary, Kenya Psychiatric Association and lecturer at Moi University’s School of Medicine www.lukoyeatwoli.com

Why budgeting for mental health care is crucial

2011-10-10T15:59:00.001+03:00

By LUKOYE ATWOLI
Sunday Nation 9 October 2011

Every year, October 10th is marked as the World Mental Health Day all over the world. This year’s theme is “Investing in Mental Health”, an issue that has been on top of the agenda for the mental health community for a long time.

Concerns about under-investment in mental health are backed by global budget figures, with the World Health Organisation (WHO) estimating that most low and middle income countries invest less than 2 per cent of their total budgets in mental health activities, the bulk of which goes to fund mental hospitals and pay workers.

In Kenya, our government continues to pay lip service to the Abuja Declaration that suggested that at least 15 per cent of the budget should be dedicated to health, and our health expenditure as a proportion of total expenditure has been declining steadily over the years. Additionally, health expenditure on mental health remains abysmal at less than 0.5 per cent, most of which goes to pay salaries and allowances of staff at ministry headquarters.

Mental ill health contributes a significant burden of disease globally, more so in low income countries such as Kenya. According to the WHO, depression is currently the leading cause of disability worldwide, and it is further estimated that one in four people will be affected by a mental
disorder at some point in their lives.

These statistics are even worse in Kenya, where no community-level intervention exists to reduce the burden of mental ill health.

No care

Due to under-investment in mental health, it is estimated that over 80 per cent of people with mental disorders in our country do not receive any sort of care, and many go through life believing that it is normal to suffer as they do.

The reason the government continues to ignore mental health in the budget might be attributed to the false perception that mental illnesses do not kill. Quite to the contrary, mental illnesses can and do kill millions of people annually.

For instance, a person commits suicide every 40 seconds somewhere in the world. Most of those that commit or attempt to commit suicide have severe psychological and social distress that can only be addressed by properly organised and funded mental health services.

Additionally, 2.5 million deaths annually are due to harmful use of alcohol, an area of immense concern in mental health. Kenya is among the countries identified as having a large proportion of people with harmful alcohol use, and it is conceivable that many of our “road accidents” are due to alcohol and other substance use.

Mental ill health also increases the risk of acquiring and dying from other serious medical conditions, including HIV/Aids, Diabetes, Cancer, and infectious diseases. Investment in mental health will, therefore, be useful in bridging the service gap in these areas, enabling the provision of care at different levels for people with mental
illness.

Budgeting for increased training of mental health personnel, improved infrastructure, hiring more staff, and providing medications and other resources must be prioritised if we are to make a dent on the burden of mental ill health.

Finally, as part of full implementation of the Constitution, the government must take steps to actualise the citizens’ constitutional right to, among other things, the “highest attainable standard of health”, a right that includes access to good quality mental health care.

Dr Lukoye Atwoli is secretary, Kenya Psychiatric Association and lecturer at Moi University’s school of medicine www.lukoyeatwoli.com

A December election date is a recipe for a disaster

2011-10-03T17:07:00.001+03:00

By LUKOYE ATWOLI
Sunday Nation 02 October 2011

The Constitution of Kenya, Article 118(1)(b) provides that Parliament shall “facilitate public participation and involvement in the legislative and other business of Parliament and its committees”. This is the spirit in which the following piece has been written.

Recently, the minister for Justice published a Bill seeking to amend the Constitution to provide for, among other things, a change of the election date from “the second Tuesday in August to the third Monday in December of every fifth year”.

In the memorandum of objects and reasons for the amendment, a couple of brief sentences purported to explain the reason behind the change of dates.

In the first paragraph, the Memorandum reads: “The Bill further seeks to bring clarity and certainty to the term of the tenth Parliament while also removing any doubts as to the date of the next general elections under the Constitution of Kenya 2010.”

The other sentence concerning the election date reads: “The Bill also proposes to amend Articles 101(1), 136(2)(a), 177(1)(a) and 180(1) of the Constitution by introducing a date that settles all controversy surrounding the date for the next general elections.” There is no mention of the budget cycle, a popular explanation from government, nor is the nature of the controversy discussed.

Legal scholar

Opinions expressed on this matter have been largely meant to justify firmly held positions. Indeed, just last week, eminent legal scholar, Prof Yash Pal Ghai and colleagues argued that the Sixth Schedule of the Constitution provides for an election in early 2013.

In reality, the only date provided for in this schedule is in part 3, Article 9(2), which provides that in case the government “is dissolved and general elections held before 2012, elections for the first county assemblies and governors shall be held during 2012”.

Obviously, the framers of this section anticipated that, all factors remaining constant, the General Election would be held “during 2012”, with the only date provided for being the second Tuesday of August.
Quite apart from the legal and constitutional reasons against a change of date from August to December, it is important for Kenyans to contemplate for a moment the implications of a December election date on the national psyche.

Let us for a moment flash back to the 2007 post-election violence. Majority of the perpetrators and victims were thought to have been young males aged between 15 and 25 years. Many of them were school-going youth, and some had just undergone initiation ceremonies that are often held during the long December school holidays. All of them were idle, and provided the perfect substrate for politicians in need of cheap hands for hire.

Research has shown that this demographic segment is the most violence-prone, especially when they are poor, unemployed and have weak social support networks. One of the ways other societies have reduced violence is by keeping these youth in school, providing employment, and offering opportunities for fulfilling social interactions when they are idle.

Is it not conceivable, therefore, that an August election date would potentially be less violent than a December one? Due to the short holiday, students busy preparing for national examinations will probably not be available for “political violence”.

If only for the sake of peaceful elections next year, we must avoid a December election date by all means.

Dr Lukoye Atwoli is a consultant psychiatrist and lecturer at Moi University’s school of medicine www.lukoyeatwoli.com

Why the buck must stop with victims of disasters

2011-09-25T10:37:00.000+03:00

By LUKOYE ATWOLI

Sunday Nation 25 September 2011

Kenya has experienced a number of mishaps in the past few days. The fire at the Sinai slums seems to have marked a turning point in our nation’s fortunes, with a series of bloody crashes on our roads resulting in a mounting body count that one member of Parliament likened to casualties of war.

Scores more died when a house they were putting “finishing touches” to collapsed in western Kenya, while in central Kenya others continued to succumb to the effects of poisonous liquor.

In the midst of all this, stringent voices have been heard exhorting Kenyans to repent and “go back to God” in order to stop any further calamities. Almost all these events are being referred to as “accidents” and a lot of the responsibility is being laid at God’s door. Of course others are going hoarse pointing fingers at government functionaries and officialdom without much effect.

When columnist Macharia Gaitho suggested that average citizens carry a significant proportion of the blame for some of the misfortunes that befall them, enraged commentators came out accusing him of being insensitive to the plight of slum-dwellers. Some argued that one cannot understand the life of the poor unless one experienced it first-hand, a classical case of insisting that one must be a chicken to criticise an egg.

No matter the level of indignation, the blame must be laid squarely where it belongs.

Proximity to the pipeline

The reason the Sinai fire tragedy happened is that poor people are living in close proximity to the pipeline, and when there was a leak, many rushed to collect the flammable liquid right from the source as it were. Buildings are collapsing because they are poorly constructed; people are being killed by liquor because they are drinking poisonous stuff; drivers are causing road crashes because they are not obeying traffic rules, are too tired, or are intoxicated and should not be allowed to drive in the first place.

The buck does finally stop with the individuals who put themselves at risk. Last week we watched on TV as a man who lives in a slum on the approach path of aircraft at Wilson Airport said he will not move despite being warned of the dangers he was exposing himself and his family to. It would have been easier to commiserate with him if he had argued that because of poverty he is unable to find alternative accommodation. His argument that “if the government wants us to build stone structures they should just say so and we will do it” was proof of the cynical impunity that pervades all strata of our beloved country.

Poverty has been made into the stock excuse for all the criminal activity we carry out, and we are bringing up children with a sense of entitlement that enables them to forcefully ask for handouts while warning us that the alternative is a life of crime.

Call to prayer

The call to prayer from all religious denominations will probably change nothing if past similar appeals are anything to go by. Kenyans will congregate and pray, and then go back to their daily routine. Instead of asking Kenyans to pray harder, is it not time our clergy embarked on a project to inculcate in their own congregants values such as fidelity to law and order and respect for human life?

Dr Lukoye Atwoli is a consultant psychiatrist and lecturer at Moi University’s school of medicine www.lukoyeatwoli.com

Why periodic famine is responsible for inequality

2011-09-19T16:07:00.003+03:00

By LUKOYE ATWOLI Sunday Nation 18 September 2011 A healthy mind dwells in a healthy body, or so the aphorism goes. Science has long established the link between mental health and physical health. Malnourished children perform poorly at physical and cognitive tasks compared to their well-nourished counterparts. This is because food provides the energy needed by both the body and the brain for peak performance. In the absence of this energy, the body’s systems slow down and only distribute resources to those functions that are essential for the maintenance of life. Higher brain functions are secondary to more vegetative functions when it comes to maintaining life and they are, therefore, likely to be sacrificed when an individual is starving. The result is sluggish thinking processes, lethargy and apathy to the surroundings. In school, this will manifest as poor performance in class, giving the impression that the individual is “dull” or less intelligent than others. A recent survey carried out by the National Cohesion and Integration Commission indicated that top government posts in this country are occupied mainly by people from the most populous tribes, especially the ones whose members ruled the country at some point. “Smaller” communities are poorly represented in government, and the main assumption has been that their “sons” have not been president, and so their “time to eat” had not come. However, the truth is more nuanced than that. It is clear that the so-called “marginalised” peoples are also the most prone to famines and food deprivation. Most of their time is spent looking for food and water, and they have little time to pursue “higher” needs in the hierarchy described by American professor of psychology, Abraham Maslow. They are, therefore, less likely to be found in colleges and universities, further diminishing their prospects of serving in government. More fundamentally, however, even when they get the opportunity to attend school alongside other Kenyans, their performance is often poorer due to malnutrition and their struggles in pursuit of food and water. The few who excel are often idolised, masking the broader impact of malnutrition on most of their siblings. The truth is that for every brilliant child from these famine-stricken peoples, there are hundreds who will never achieve much in school, the primary reason being that starvation has significantly reduced their intellectual capabilities. In my view it follows, therefore, that anyone interested in redressing the ethnic imbalance in employment and intellectual achievement will invest in improving the food availability in the arid and semi-arid regions. Focus on reducing child malnutrition alone will ensure that those that go to school will compete on an equal footing with their colleagues from other parts of the country. Obviously, then, affirmative action is not sustainable. The horizon for solving the problem must be long-term, focusing 20 or 30 years from now, where the ideal should be that no region in this country should suffer the rates of malnutrition that are being seen in Turkana and contiguous areas. I would encourage public-spirited Kenyans to take the government to task on this issue. Allowing some regions to continue enduring starvation in this day and age is not only inhuman, but also amounts to a culpable dereliction of duty that ranks up there with genocide and other crimes against humanity. Dr Lukoye Atwoli is a consultant psychiatrist and lecturer at Moi University’s school of medicine www.lukoyeatwoli.com

Perhaps Kenya needs a new story besides politics

2011-09-13T22:01:00.000+03:00

By LUKOYE ATWOLI
Sunday Nation 11 September 2011

This past week, the confirmation of charges hearings of the Kenyan cases at The Hague were the only subject of conversation everywhere one turned. Total strangers would stop each other in the street to discuss how the hearings will turn out. Everyone has an opinion on the quality of the lawyers or witnesses, and which side is obviously winning. Every evening, dozens of Kenyans are glued to television screens listening to legal jargon and trying to make sense out of it all, and only end up confirming their own prejudices.

The Hague trials have only confirmed for me one trait that could be said to be authentically Kenyan — the love for political drama. Every election season This scenario actually repeats itself every election season in a major way, when politics is all we can talk about. After the elections we spend the next four or five years discussing political realignments, and soon another election catches up with us. In public places on any given day, all TV sets will be tuned in to the region’s favourite channel at “news time”, and all activities stop to allow us to “catch up with the news”.

Every morning we voraciously devour the same news as presented in our favourite dailies, with those who cannot afford a newspaper borrowing from another buyer or the news vendor. In short, our national life is now defined by the drama inflicted upon us by politicians and wannabe politicians. Amazingly, this unending dalliance with politicians has caused us much grief, but we are loath to let go.

Perhaps it is time we started defining a new reality for those of us who refuse to be pigeonholed into a “type” or typecast into predefined roles. It is in this connection that I would like to flag two special events that will take place this coming week whose significance may only come to be appreciated decades from now.

The first is really a very humdrum scientific conference discussing reproductive health, with emphasis on prevention of maternal deaths. This meeting, due to be held at the KICC on Thursday and Friday this week, will examine the progress made since 2005 when a similar conference was held and several resolutions made. Has the situation improved since then? Yes and no.

Yes, because we now have a new Constitution that attempts to provide health, including reproductive health, as a constitutional right. It also now prescribes clearly the
circumstances under which abortion is allowed. The negative assessment concerns the rate of maternal deaths, which has remained relatively constant since 2005, and currently stands at just under 500 maternal deaths for every 100,000 live births. Perhaps this conference will come up with something radical enough to prevent my wife and sisters from facing the very real risk of dying as a result of pregnancy.

The second event is concerned with the very literal task of rewriting our country’s story. This is the Storymoja Hay Festival, which will be held at the Railways Sports Club
grounds in Nairobi from Friday to Sunday this coming week. Poetry, prose of all types and books will be discussed, bought and sold. Writing workshops will be held for budding writers, and hopefully everyone will have fun and learn something at the same time.

It is my hope that these events, and not The Hague hearings, will define this coming week.

Dr Lukoye Atwoli is a consultant psychiatrist and lecturer at Moi University’s School of Medicine www.lukoyeatwoli.com

The tasks ahead for the new doctors’ union

2011-09-04T10:07:00.000+03:00

By LUKOYE ATWOLI
Sunday Nation 04 September 2011

Last week, the Kenya Medical Practitioners, Pharmacists and Dentists’ Union (KMPDU) was registered.

Coming on the first anniversary of the promulgation of a Constitution that guarantees labour rights to all workers, this happy event demonstrated the extent of openness that now permeates most of our sectors.

As the new union gets down to business, the members must now think of electing leaders who have the interests of the health worker at heart, and who have experienced first-hand the suffering that these professionals go through in the execution of their daily tasks.

It is my conviction that the success of this union will improve not only the lot of all health workers, but also the standards of health care delivery.

The union will provide the forum through which the government may be compelled to explain the recent policy changes that stopped funding for postgraduate students in the various medical specialties.

Escalating human resource transfer to the private sector is evidence of rampant maltreatment of these highly trained professionals, whose only demand has traditionally been reasonable working conditions as per the law.

Today’s health workers demand a proper working environment and reasonable working hours, adequate facilities for work, and commensurate remuneration for their efforts.

The fact that the entire nation trusts its health in the hands of these few individuals clearly demonstrates the importance of the work they do.

As we have argued before in this column, the time has come for the health ministries to produce legislation that will create a regulatory body bringing together all health workers’ professional licensing boards.

This body, similar to South Africa’s Health Professionals Council, would be responsible for licensing and professional regulation of all health workers, as well as setting standards for ethical and quality health care.

In the absence of such a body, the constitutional provisions on health risk being handled haphazardly, resulting in the negation of their spirit and intent. For instance, the controversial provision on abortion and the beginning of life cannot be resolved by politicians or even the courts. Only a body comprising health workers will translate this provision into a tangible and enforceable regulation.

Other areas that will need professional interpretation by a statutory body include definitions of ‘emergency medical treatment’, ‘reproductive health’ and even ‘highest attainable standard of health’ as provided for all Kenyans under the Constitution. This council will be in a position to prescribe what the minimum package of health care would meet this constitutional threshold for health rights.

In my view, the doctors’ union must position itself together with the other health professional associations such as the Kenya Medical Association in agitating for the formation of this council to safeguard the standing of the professions. In the face of official reluctance to create this body, the union must be prepared to play this role in consultation with other professional bodies.

Finally, in order to be successful as the representative of the social welfare of diverse health professionals, KMPDU must embark on a massive membership drive, and it would probably be useful to encourage all doctors employed by diverse organisations to join in order to more effectively negotiate for better working conditions, and better health for all Kenyans.

Dr Lukoye Atwoli is a Consultant Psychiatrist and Lecturer at Moi University School of Medicine www.lukoyeatwoli.com