Dr Kennedy Muindi Kithome, MD, MPH-Candidate School of Public Health – University of Nairobi
The constitution of Kenya provides that every person has the right to the highest attainable standard of health, which includes the right to health care services (art 43. 1 (a))
According to schedule 4 of the 2010 Kenya constitution, majority of government functions have been devolved to the 47 county governments. Health is one of these devolved functions, and COVID-19 response is being coordinated in this decentralized fashion. What then should a healthworker do when they find themselves in a county that is unprepared for the coming surge of COVID-19 patients?
The government being a signatory to the Abuja Declaration, committed in 2001 to allocate at least 15% of GDP to Health. Since the promulgation of the constitution, the average spend has hovered around 7% (https://pesacheck.org/how-much-of-kenyas-budget-is-going-towards-the-health-sector-5ee2040b1f5). This chronic underfunding has engendered shortages in key elements of health system building blocks needed to meet the constitutional prerogative, leading to industrial action by health care workers (HCW) as a last resort to force change.
Strikes are a common occurrence in Africa. Between 1996 and 2015, there were 620 strikes in 38 African countries, 18% of which were of national impact. In Kenya, between 1995 and 2014, there were 32 local strikes across 11 counties and 16 separate hospitals. Between 2010 and 2016 there were 6 national strikes ranging from 9-42 days in duration. The mammoth healthworker strikes of 2016 and 2017 disrupted health service provision for 250 days in 11 months that year: the doctors’ strike lasted 100 days while the nurses’ strike went on for 150 days.
COVID-19 has exposed the ugly underbelly of weak, underfunded and ill-equipped African health systems lacking the resilience to pivot and react to unexpected challenges. As of this writing, the National Association of Resident Doctors Nigeria has staged an indefinite walkout citing lack of hazard pay and woefully inadequate PPE. They also demanded an end to harassment of healthcare workers by security officials enforcing curfews. Here in Kenya, Kisumu County healthcare workers temporarily halted their strike on 24th June. Their grievances include delayed salaries, long overdue promotions, inadequate PPE and unpaid COVID-19 risk allowances. Pumwani Maternity Hospital in Nairobi County has had 41 out of 290 tested healthcare workers turn positive and put out of action through home-based isolation owing to the fact that 90% of them remain either asymptomatic or exhibit mild disease. Upwards of 100 deliveries are conducted there daily. The remaining members of staff are said to be on a go-slow.
The Kenyan healthcare worker is facing the same challenge as the Nigerian healthcare worker. The questions that hovers unasked are, even if industrial action is legal, is it right? Is it also right for an ill prepared healthcare worker to walk into the face of certain infection and likely death while fulfilling their obligation to their patient as spelt out in the Hippocraric Oathand Florence Nightingale Pledge? Is medicine essentially a matter of technique, a skill of science? Or is it a matter of moral commitments in the exercise of clinical skills? Is medicine or nursing a calling or a job?
Healthcare workers possess special skills and hold a monopoly of medical knowledge and expertise. The oaths they swear bind them to certain duties to patients for their good, call on them to avoid injustice and refusal to harm, not just what the patient wants.There is, embedded in the pledges, recognition of power of special knowledge as well as a recognition of limits of expertise The conduct of healthcare is governed by a social contract: parties agree to their rights and responsibilities. There is also an element of commercial contractual obligation in the private healthcare setting, where services are delivered for payment. When one of the parties reneges on the obligation, there is a conflict which often escalates as neither party is willing to back down. This leaves the potential beneficiaries of health services in the firing line with absolutely no recourse.
There are no easy answers to this. While healthcare workers have a duty of care, legal and moral responsibility, how they act in ambiguous and crisis situation may come down to personal beliefs and values. Some healthcare workers may conscientiously object– refuse to perform their duties citing clear and present danger to self and a plausible moral rationale. In line with the principles of respect for autonomy and justice, this act may be ethically defensible. One may also reasonably argue based on utilitarian principles that the short term suffering induced by doctor and HCW strikes can be mitigated by the long-term benefits such as improvement of healthcare services for the greatest number of people over time.
I have previously written about how the use of war terminology in describing the response to COVID-19 has been detrimental in several ways, among which are inducing a sense of fear in the civilian public. Also, many members of Kenyan communities borders that reside near international borders have family across frontiers; framing Kenya’s COVID-19 response as a war against outsiders who may seek to destabilize us by re-importing the virus also rubs these fellow citizens the wrong way.
Another theme, still under Health System weakness and closely tied to healthcare worker vulnerability is ethical dilemmas falling on individual healthcare workers, such as decisions on who to give or deny critical care to. One of the ways out of this ethical minefield is to shift the task of deciding who gets lifesaving treatment and who doesn’t out of the hands of individual healthcare workers. Advance directives are written instructions stating what an individual would regard as an acceptable future quality of life, and whether they would refuse ventilator support or other life-sustaining procedures if these are not in line with their stated wishes. The presence of advance directives would remove the onus of for example, deciding to remove an elderly patient with poor prognosis for a younger patient more likely to survive. In Kenya, the strange push by persons of means for ICU beds in their private homes may inadvertently work in the favour of the public who may soon be scrambling for the few ICU beds available.
It is also important to frame the conversation in terms of reciprocity: healthcare workers have a solemn duty to provide care, but governments have a sacred duty to provide them with the wherewithal to do their job. The recent trend seen the world over where healthworkers have been branded heroes may have the unintended consequence of saddling doctors and nurses with the unenviable task of going beyond what may be morally permissible, to their personal detriment, in addition to stifling any conversation on what the limits of their duties are.
In the COVID-19 pandemic, the risks to healthcare workers are appreciably greater than those encountered in normal practice. In addition to risk of contracting the infection, other risks include physical and mental fatigue, the torment of difficult triage decisions, and the pain of losing patients and colleagues, are amplified several fold. The idea that the duty of care is limited, even in the current pandemic, is evidenced by the fact that Kenyan healthcare workers with pre-existing medical conditions which put them at higher risk of suffering serious COVID-19 complications have been advised to avoid patient-facing roles. For these healthcare workers, working with patients would thus represent an unacceptable level of personal risk, and would exceed what is required by the duty to treat.
This is precisely why reciprocity is key: in return for accepting personal risk in fulfilling their duty to treat, healthcare workers expect reciprocal social obligations. States are obligated to support workers and acknowledge their work in difficult conditions. They need to provide adequate PPE to minimize risk of healthcare workers contracting the virus while providing care. Healthcare workers need risk communication to be clear and unambiguous. Healthcare workers need adequate training, support and resources to carry out their duties. Healthcare workers need counselling and psychological support to help them deal with the mental strains of working as COVID-19 first responders. Healthcare workers need guarantees that should they fall ill they will be afforded care.
In conclusion, the ethics of providing care by healthcare workers during COVID-19 remain rooted in ethical principles of duty of care and justice, with the proclamations of the various oaths they take cementing these principles. Inasmuch as healthcare workers are duty-bound to provide these vital services, society is as well duty bound to respond in a reciprocal manner, by providing all that is necessary for these professionals to safely do their jobs, and by agreeing to follow public health guidelines, potentially reducing infection rates and safeguarding health systems from unmanageable surges.
 “I shall be loyal to my work and devoted towards the welfare of those committed to my care”.)
 “I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.”