Thirty-five miles away from our base in Embu is the Kenyan town of Nyeri.
It is infamous for having a diabetes rate of 12.6% - the highest in sub-Saharan Africa, according to the World Health Organisation. It’s also more than double the prevalence of diabetes in the rest of Kenya.
A recent survey in rural Kenya also showed that 21% of the population had hypertension. Of this group, only 3% were being successfully treated while 83% were unaware they had high blood pressure.
It is clear that non-communicable diseases are becoming a major health problem in low to middle-income countries, overtaking infectious diseases as the main cause of morbidity and mortality.
It's not just Embu County, Kenya as a whole suffers from above average rates of diabetes and hypertension. However, there is no clear-cut reason for this.
The standard answer is increased consumption of meat and processed food, rather than whole grains, vegetables and fruit, leading to obesity. This is then exacerbated by declining physical activity and the increased use of motorbikes, buses and cars. Tobacco and alcohol are other risk factors.
However, in Embu, we see patients who do not fit this stereotype. They are thin, they work hard on farms to grow fresh food and they neither smoke nor drink alcohol. There is probably a strong genetic factor that only comes into play as people are living longer.
A new approach
In August 2017, MSF started working with Embu County Ministry of Health to support the management of four non-communicable diseases in rural health centres and dispensaries.
Instead of herding health workers into classrooms and lecturing them about hypertension, diabetes, asthma and epilepsy, we adopted the innovative approach of mentoring.
Over six months, trained MSF mentors will make weekly visits to seven health facilities around Embu. They'll provide personal tutoring and training for Ministry of Health staff on a one-to-one basis using specially designed guidelines for treatment.
However, it isn’t all about clinical officers and nurses doling out pills to patients.
Another important aspect of our programme is providing health promotion and patient support. Again, this is done using a mentoring approach for our community health volunteers.
In three health centres, patients have even formed their own support group.
There is some evidence that support groups improve a patient’s compliance with their treatment. For example, group members are twice as likely to take their medication as prescribed and less likely to drop out of treatment compared to patients who are not part of a group.
What do the groups do best, though?
They offer a friendly, safe, social environment for patients to come together and share their experiences in confidence.
Groups talk about the challenges they face living with their diseases and discuss strategies to overcome them. Members are eager to learn more about their condition and invite specialists to talk. They raise issues and push for change.
Earlier this month, we attended a support group for patients with diabetes and hypertension.
It’s winter in the Kenyan Highlands and the weather was atrocious. It reminded me of those damp, misty November days in England.
We were not expecting all 25 group members to attend, but 23 turned up and the chairman, Mr John, started the meeting on time. One member was almost blind. Another had such painful diabetic neuropathy (damaged nerves in her legs and feet) that she could only wear flip-flops with socks.
After introductions, each member spoke about their illness and how they were managing it. Here are some of their thoughts:
- “Since joining the programme, I have not spent a single shilling on drugs. I used to spend a lot of money buying medicine. When I didn’t have money, I couldn’t pay for medicine. My greatest happiness is that I have not missed a single day of treatment.”
- “I thank the team from MSF because they never come late. They start work immediately and do not leave until the last patient has been seen. They treat everyone the same and with compassion."
- “I can stand and dance now. I can dance and move every part of my body.”
- “When I was diagnosed with hypertension and diabetes, I was very worried because I am not overweight. Now, I have been taught to accept my condition and manage it myself. I followed the instructions and take my medication daily. My blood pressure is now controlled. I took the education very seriously.”
- “At first, I had many tests without a proper diagnosis. When I came here, I was put on a treatment programme and within a short period of time I was already feeling an improvement. Now I feel as strong as a soldier.”
Everyone said prayers and sang songs to get the meeting going. Despite being invited, I didn’t join in the dancing (I have previously been described as dancing like Mr Bean).
Elizabeth, the Embu County coordinator for non-communicable diseases, came to observe the group. She emphasised the close collaboration between MSF and the county in addressing the diseases. And, from the way she participated in the dancing, I think she enjoyed the meeting.
Rachel, our health promoter, gave a short presentation and Purity, our clinical officer, gave an interactive talk and got the group to answer questions.
Although the prevalence of diabetic foot problems is relatively low, a few patients wanted to highlight how important it was to look after their feet and to use proper, comfortable footwear.
One patient described more worrying symptoms and we made arrangements for her to see the MSF doctor who provides technical support to the team.
Several patients complained about eye problems, which are common in diabetes. There was a move to invite the local ophthalmologist to come to the next group meeting to answer questions. Unfortunately, the hospital clinic in Embu cannot dilate pupils to get a good look at the back of the eye and there is no laser treatment available to deal with diabetic retinopathy.
Judging by the frequency and variety of the ringtones interrupting the meeting, the patient support group is familiar with social media. So, I wondered about forming a WhatsApp group, using the local language, where group members can communicate with each other.
The group invited the health centre workers who were being mentored by MSF to attend the next meeting. We strongly encouraged this in order to show that their health workers had the knowledge, skills and attitude to manage non-communicable diseases just as well as their MSF mentors.
This was only the group’s third meeting, but there are already signs that soon they will be able to manage on their own.