Thursday, April 17, 2014

‘Healing’ crusade poses serious health risk

By Lukoye Atwoli
Sunday Nation 13 April 2014

Kenyans are a highly religious people. This is borne out not only by their open declarations of religious affiliation, but also by their often overzealous demonstration of religious fervour whenever they are called upon to do so. This, in itself, is not a bad thing. It might even be a good thing, especially in circumstances when this religious zeal is directed at activities aimed at improving the lot of needy individuals or humanity at large.

Unfortunately, due to the nature of religious belief, occasional tragedies occur. There are multiple examples of this, and it is pointless to rehash them here. The reason they occur is that the average religious person takes the message from their holy book or their cleric literally. Many proclaim that their clerics are messengers of their deity, and the holy book is the unquestionable transcription of the deity’s words. Sometimes the outcome of this blind obedience is serious harm and even death, but even these are explained away as the doings of an inscrutable deity.

Over the long Easter weekend, one such cleric will descend upon Eldoret with the professed mission of spreading the message of repentance and holiness. As has been the practice in previous crusades of a similar nature, it is expected that many will ferry their sick relatives from far and wide, and present them to this preacher who is also fabled to be a faith healer. 


Those of us taking care of thousands of Kenyans with chronic conditions will be waiting for the inevitable outcomes with dread. We know many patients who have already abandoned their medications and clinic follow-ups in anticipation of healing at the crusade, and dozens more who will attend the crusade and abandon their treatment.

We dread the reports we shall get when we follow-up patients with chronic conditions like HIV, cancer, diabetes and mental illnesses to their homes. We fear we will be told some of them died after being convinced they were healed at the crusade thus stopping their life-preserving treatments. We fear we will find them at home, wasting away while believing fully that they have either been healed, or that healing is on the way.

We dread the events we shall continue to encounter in the clinics of the Moi Teaching and Referral Hospital, weeks and months after the four-day crusade. Many patients will show up in deplorable health and, when asked what happened, they will say that they thought they had received healing at the Easter crusade. Many more will suffer irreversible damage due to chronic illness, and will return to the hospital only at the urging of worried family members.

Why do we raise the red flag at this point, before the crusade happens? Because we believe it is still within the powers of the organisers of the crusade to do something about it and ensure that no lives are lost, and no one goes home in worse health.

The organisers and preachers should announce to their faithful that nobody should stop taking their medication or stop attending their regular clinics, in anticipation of healing. That simple message will save dozens of lives, and ensure continuing good health for countless others, which one would expect is a good thing for the organisers of the crusade. 

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine.

Friday, April 11, 2014

Jubilee one year on: Analysis of health pledges in Jubilee Manifesto

Free maternity keeps Uhuru and Ruto health pledge (I didn't do the headline!)
By Lukoye Atwoli
Daily Nation, Wednesday 09 April 2014

Soon after his inauguration, President Kenyatta declared that all maternity care would be offered free of charge in public facilities. Many commentators equated this pronouncement to President Kibaki’s free primary education pledge that was made so early in his term that many thought it would fail. One may suppose that President Kenyatta made his “free maternity care” pledge in this same spirit, and hoped that things would come together somehow and make it work.

To some extent, this has happened in many parts of the country, and the government says that hospital deliveries have registered a significant rise from 40 per cent to 66 per cent. However, there have been hiccups in some parts of the country where, due to limited financing, some counties have decided to start charging for some of the services.

To some extent, the fortunes of the health sector under the Jubilee government may be encapsulated in the success or failure of the free maternity care initiative. In the Jubilee manifesto, party leader Charity Ngilu, now a Cabinet Secretary, indicated that she joined the Jubilee coalition on the basis that it would “ensure that all Kenyans get quality and affordable healthcare.” This then became a key plank in the new government’s agenda, perhaps explaining the President’s haste in providing solutions for the sector.

The coalition identified bureaucracy and corruption as major impediments to improving health services, and further argued that the National Hospital Insurance Fund (NHIF) is “bloated and corrupt”. Brain-drain involving health practitioners, especially doctors, was mentioned as well. The coalition indicated that their first focus would be on preventive health, and universal healthcare was to be rolled out through local primary healthcare centres. Finally, the coalition’s stated intention was to make Kenya an international medical hub with an increase in medical tourism by adopting the “successful Indian model”.

Several specific pledges were made in the manifesto as the method by which the coalition would reach their healthcare goals. The coalition pledged to increase health financing from 6 per cent to 15 per cent of the budgeted expenditure, perhaps to bring the country into compliance with the Abuja Declaration target.

The number of physical facilities were to be increased, bringing a health facility to within five miles of every home, and many previous provincial hospitals were to be upgraded and equipped to the status of referral hospitals. Diagnostic centres for all conceivable illnesses were to be set up, and free mosquito nets would be distributed to all families in need.

Better nutrition was to be encouraged, and medical research, including on indigenous medicine was to be promoted under the Jubilee coalition government. E-health and private sector participation was also to be encouraged and promoted, and pay packages for doctors and other health workers were to be improved.

One year down the line, an evaluation of the Jubilee pledges comes up with perhaps one major success story.

Free maternity care is now government policy, and many facilities across the country are not charging mothers to deliver or get other services related to childbirth. This is a huge plus especially in rural and poor settings where mothers preferred to deliver at home, assisted by local midwives or other women, than go to hospital and have to pay what they considered to be exorbitant rates.

On the whole, however, it is difficult to find much to write home about what this government has done with regards to healthcare. Healthcare financing continues to be meagre, and in the last budget, the national government allocated 2.1 per cent of expenditure to health. It is not known what the counties collectively allocated to health, but the few that were analysed had allocated less than 3 per cent of their budgets to health as well.

The government started out on a bad footing when they appointed both a Cabinet Secretary and a Principal Secretary who were not healthcare professionals, going against the pledge made by Deputy President William Ruto in the Manifesto. This had the effect of delaying any serious initiatives in the sector, given that the two senior officials required a crash course in the sector and how it works.

One of the key handicaps faced by this government is that the manifesto did not take into consideration the changed healthcare environment, with the constitutional shift of primary healthcare and some curative services to the counties. Without a mechanism of ensuring cooperation of the county governments, it is therefore difficult to operationalise many of the pledges concerning healthcare at the county level.

Today, strikes in the sector are an everyday occurrence, and recent reports indicate that many doctors are leaving the civil service to go abroad or into private practice as a result of problems with their terms and conditions of service in the counties. The legislative and policy framework has not done any better. Four years since the coming of a new Constitution, health is the only sector that has not been re-formatted legislatively to conform to the law. The Health Bill has remained in draft form for a long time, and stakeholder involvement in its drafting and progress has been reluctant and limited.

As far as the health sector is concerned, the Jubilee coalition rates a very modest score. 

Dr Atwoli is a senior lecturer, Moi University School of Medicine and national secretary-elect, Kenya Medical Association.

Wednesday, April 9, 2014

Is it time to regulate religious teachings?

By Lukoye Atwoli
Sunday Nation 06 April 2014

Kenya seems to be in the throes of a major social convulsion and time has come for us to confront certain demons that represent a major threat to our continued survival. Lately, a new monster that had remained largely under the surface has emerged, in the manner of “religious extremism”. This has been blamed for incidents of “radicalisation” of youth, and even some of the terrorist attacks that are becoming common.

However, this term is, in my view, misleading. As part of some research I have done in the past, I have asked dozens of religious practitioners what constitutes an extremist or fundamentalist. Even within the same religion, different responses are given. For instance, some argue that an extremist is one who takes a literal interpretation of their religious book or teachings, and behaves accordingly.

Others contend that extremists “misinterpret” religious teachings and use them to harm others. The problem with this argument is that it assumes that everyone, including non-adherents, understand what teachings are actually being misinterpreted. When pressed, those with this opinion argue that no religion teaches intolerance or hate, and none condones murder of “innocent” people.

Unfortunately, a plain reading of the holy texts of the religions that are dominant in Kenya reveals a different picture. Many passages condone the killing of those that are regarded as non-believers, and condemn to death and eternal suffering those that deny the existence of the deity to whom the book refers. Although there are many other passages describing “upright” behaviour and being available to help other human beings in need, it is difficult for an ordinary adherent to determine what is to be done and what is to be avoided on the authority of the holy book.

From a secular perspective, one is left in the difficult position of determining what conforms to religious teaching and what does not. When someone argues that the holy book teaches one thing or the other, it is difficult to contradict them, even if other sections of the same holy book teach quite the opposite.

What is known is that no religion teaches their adherents to be “lukewarm” or to pick and choose what to believe and what to leave out. Both Christianity and Islam hold their holy books to be comprehensive and infallible. They are considered to be either direct utterances of the deity, or material written under the direct guidance of the deity.

If we are to accept that religious extremists or fundamentalists either misinterpret or distort religious texts, then it follows that one cannot gain complete religious insight from a plain reading of the religious texts. It follows also that for one to fully understand the teachings of a particular religion, there is more learning to be had outside of a plain reading of the religious text. 


This begs the question why then religious preachers are so poorly regulated. Almost anyone in this country can start a sect and be allowed the freedom to propagate their teachings without let or hindrance. Perhaps religious institutions should be regulated in much the same way the various professions are regulated, in order to ensure that their teachings do not run afoul of the aspirations of our nation as enshrined on the Constitution.

The alternative is to contend with continued religious “radicalisation”. 

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine.

Tuesday, April 1, 2014

Wage bill debate sets stage for law review

By Dr Lukoye Atwoli
Sunday Nation 23 March 2014

Finally, and as predicted, the motive behind the recent wage bill ‘conversation’ is becoming clear. Already there are moves in Parliament to reduce the number of elected representatives ostensibly because someone has determined that they are a major contributor to the allegedly ‘ballooning wage bill’.

Apparently we must get rid of women members of the National Assembly, nominated Members of Parliament, members of the county assembly and even reduce the number of counties in order to reduce recurrent expenditure.

An interesting observation about this whole charade is that it is obviously being led by people who have always been opposed to the new Constitution. They have now repackaged themselves into protectors of our national expenditure, and are proposing moves meant to improve our economic position. Their real goal, as is now becoming evident, is to subvert the currently established constitutional order and revert to the authoritarian model in which all authority vested in the president, who was considered for all intents and purposes to be above the law.

This whole venture is extremely dishonest. Over the last three years or so, health workers have engaged the government in dialogue aimed at rationalising the national health workforce in order to improve service delivery to Kenyans. To this end, they have repeatedly suggested the need to have a health service commission that would register, recruit and deploy all health workers in the country, based on needs identified by the counties. (READ: Team set up to cut costs starts work)

The stock response from the government has been that such a move would require a constitutional amendment allegedly because the Constitution has vested all public human resources in defined constitutional commissions, and the health service commission is not one of them. Further, the Cabinet Secretary for Health is on record claiming, fallaciously one must add, that all health services have been devolved under the Constitution. 


The point of this example is that the political establishment has determined that it is next to impossible to enact legislation addressing key human resource concerns in the health sector, but is now attempting to legislate far-reaching changes in the constitutionally provided structure of government.

Predictably, these bills will move at breakneck speed through the Houses of Parliament as long as they enjoy the support of the ‘owners of government’. (EDITORIAL: Government wastage has become appalling) Politicians have indicated that even if it takes a referendum to enact the changes they are interested in, then that is the route they will take.

All this action is being taken, of course, in the interest of reducing the wage bill. One wonders if anyone else can see the ludicrous chain of reasoning behind such moves.

As has been argued before, more immediate measures can be taken to control expenditure, including cutting fraud, waste and abuse in government offices. Streamlining procurement procedures and consistently punishing corrupt officials will definitely yield dividends that will see the economy grow sustainably. More importantly, though, taking measures to increase our national income and productivity will be the key drivers of economic growth. Cutting public workers’ pay will not.

It would therefore serve our legislators well to focus on keeping the Executive on its toes, instead of wasting time singing the Executive’s chorus whenever they are called upon to do so. All this bickering is only serving to reduce investor confidence in the state, and no amount of wage bill cuts will bring this back. 

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine.

Marriage Bill harms rights of the mentally ill

By Lukoye Atwoli
Sunday Nation 30 March 2014

Two things caught my eye this past week, and both are worthy of comment. First, our National Assembly passed a Marriage Bill that has elicited all manner of comment, ranging from polygamy to gay marriage. Unfortunately, combing through the Bill, one comes across several instances of senselessly discriminatory clauses, chiefly against people with mental illnesses.

For instance, the effect of Clause 12(a)(ii) of the Bill is to prohibit people with chronic mental illnesses characterised by recurrent episodes from getting married. Similarly, Clauses 66(6)(g) and 73(1)(g) make such mental illnesses legitimate reasons for voiding or annulling a marriage.

The net effect of the Marriage Bill as debated and passed in Parliament is to ensure that a diagnosis of a chronic mental illness would mean that the individual cannot legally get married. It also means that even if one is already married, if they are found to have had a chronic mental illness with a chronic recurrent course, their spouses could legally petition for the marriage to be annulled.

The problem with this bill, as with all legislation that purports to use mental illness as a reason to restrict people’s rights, is that the originators clearly do not have an understanding of what constitutes mental illness. 


Current research evidence suggests that between 10 and 25 per cent of our population suffers from a serious mental illness. The import of the Marriage Bill is that this large segment of our population would be condemned to a loveless life in which any attempt at a long-term relationship would be null and void.

Before he assents to it, the president must subject this bill to thorough scrutiny by mental health professionals in order to cure it of these discriminatory and unconstitutional provisions. However, if he agrees with the intent of the bill, which is to prevent the mentally ill from contracting legal marriages, he must demand a clause that requires that everyone of marriageable age undergo periodic psychiatric evaluations that shall determine whether they can get married, or if already married, whether the marriage may continue to be recognised under the law.

This, of course, means that he will have to budget for the training and recruitment of a huge number of mental health specialists in the coming years to help implement these provisions. Perhaps this is not such a bad thing after all!

The second issue that caught my attention were media reports alleging that Catholic Cardinal John Njue had raised misgivings about a tetanus vaccine aimed at preventing maternal and child illness and deaths related to childbirth. He allegedly termed the mass immunisation campaign “fishy”, and urged his followers to further interrogate this vaccine.

The cardinal, when he speaks, is assumed to be speaking for the Catholic Church. Devout followers of the Church are expected to hang onto his every word, and look up to him for spiritual guidance. When he suggests that a vaccine may be dangerous, at least some of his followers will take him seriously and start refusing it. The result will be potential illness and deaths that would have been prevented by the vaccination.

Before making such potentially harmful statements, religious leaders would be well advised to seek competent guidance from experts in the field, many of whom may be found among the faithful of the church. 

Dr Atwoli is a consultant psychiatrist and senior lecturer at Moi University’s School of Medicine.