Safari Doctors Outreach July 2016 Report

SAFARI DOCTORS OUTREACH JULY 2016 REPORT

July 24-26,2016

ROUTE & SERVICES RECOMMENDATIONS ACKNOWLEDGEMENT A glance at the work of Based on the clinic outcomes Meet the hearts behind Safari Doctors and the across the 4 villages, there Safari Doctors that have services delivered over was a significant learning enabled service delivery. the month of July. curve for Safari Doctors. Also connect with CNN Heroes feature of Safari Doctors and Founder. Page 1 Page 9 Page 12

ROUTE AND SERVICES Up along the northern coast of Kenya, a traditional dhow sets sail to deliver primary health care services to the remote villages of The July outreach across the four the Lamu. Safari Doctors Initiative emphasizes villages illustrated significant cost-effectiveness and focuses on providing both basic medical care and preventative care to the differences in the trends of remote areas of the Lamu archipelago. The treatment administered. There is initiative specifically focuses on getting services a wide variation of medical out to the Aweer and Bajuni communities that are strongly affected by militant extremism and conditions in particular areas. security operations that has left the communities in even further isolation.

At 4am Sunday morning of 24th July Safari Doctors embarked on an outreach clinic that would last two nights and three days spanning across four villages (Kiangwe, Mkokoni, Kiwayu cha Ndani and Siyu). The service delivery team comprised one medical officer, three nurses and one administrative assistant.

Thanks to the support of the Village Experience who specifically supported this July outreach, the clinics provided services to 327 people, 80% of the targeted population for the four villages. The clinic consisted of a basic triage, diagnosis, wound care, medicines, immunizations, and antenatal care. This was the first time Safari Doctors has visited Mkokoni and Siyu, we are looking forward to building those relationships with those communities to develop on-going healthcare support.

Safari Doctors trialed a new triage, medical assessment, referral form and range of medications for this outreach with support from a Volunteer Medical Coordinator from Doctors of the World, UK.

Lessons Learned…

The July outreach across the four villages illustrated significant differences in the trends of treatment administered. There is a wide variation of medical conditions in particular areas.

This makes the prediction of conditions more difficult for future outreach, particularly when there have been continuous changes with each previous mission, for example the spread of a gastric infection (due to previous poor sanitation, chlorine was provided as follow up). It is therefore important that Safari Doctors help to prevent outbreaks where possible (through regular sanitation supply and education), combined with communication with communities before outreach to predict disease prevalence, and have a variety of treatments available to account for various presentations.

By increasing the range of medicines available, Safari Doctors were able to provide for such a variety of conditions, and see where more specific supplies are required for future outreach. With the break down for particular health needs per village now available, this can help to organize the distribution in the future.

From these assessments it was also notable that clinical pathways could be introduced to allow for consistency in the diagnosis and treatment of certain common conditions. Therefore, if a prevalence of specific conditions is indicated prior to outreach, medicine procurement can be adjusted according to the clinical pathway to allow for more accurate expenditure on medicines, and therefore more informed preparation that meets a predicted need.

…This makes the prediction of conditions more difficult. It is therefore important that Safari Doctors help to prevent outbreaks where possible through regular sanitation supply and education

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Demographics

The graph displayed below allows Safari Doctors to plan according to the specific demographic mapping of each area that received treatment and total amount within each category for the outreach clinic in total. This allows predictions in the amount of treatments required for under 5 year olds for each village, for example in immunizations, multivitamins and pediatric medicines, where to target for family planning and antenatal care (ANC) input, or a majority of adult conditions such as diabetes and hypertension

Demographics for July Outreach Clinic

140

120

100

0 Total Women Men Children Under 5 Years Old

Kiangwe Mkokoni Siyu Kiwayu

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Kiangwe Village

In Kiangwe we treated and diagnosed a majority of acute infections; including respiratory (36%), parasitic (25%), skin conditions (11%) and ears, nose and throat (ENT) cases such as eye infections (8%). Within the respiratory conditions were some symptoms indicating possible tuberculosis (TB) infection. A specific outreach team who will be able to test for the condition and provide the necessary treatment will follow up these cases. This outreach clinic in Kiangwe has therefore played a role in infectious disease monitoring. With a variety acquired infections that may be related to living standards or access to sanitation, further outreach may focus on providing these basics (such as soap and chlorine) and support the community health volunteers to provide education to the village on these issues.

Kiangwe Presentations Kiangwe Diagnosis

Acute Chronic Respiratory Parasitic Anemia Immunisations Family planning Dermatology ENT Injury Malaria Test Gastric

Kiangwe is a village that has been severely We set up in an abandoned building, hosting affected by insecurity; they no longer have a soldiers who protect the people here from the Al school or medical facilities to serve the Shabaab attacks. They are triaged under a tree community there. They have visits from Kalu, and then allocated to the doctor for consultation, the Safari Doctors Lead Nurse, who provides at nurse for treatments, immunizations or ANC, and least antenatal care and immunizations. The finally the mobile dispensary. outreach clinic comes as relief to the village for those who may not be able to see a doctor or receive medicine, unless they are able to make a dangerous journey into mainland or expensive boat ride to the district hospital in Lamu.

4 Safari Doctor’s visiting Medical Officer, Dr. Swaleh, sees a young seven-year-old boy with a traditional method of ‘casting’ a broken arm with leaves, sticks and string. He has an obvious deformity of his left radius and ulna, an injury over a week old that should have been treated with surgery. He is given appropriate painkillers and referred to the district hospital, where he will unfortunately need an operation to re-break the bones and reset them correctly.

Mkokoni Diagnosis Mkokoni Village Located further north of the Archipelago, Mkokoni village is equipped with a nurse and support worker. The facility is adequately staffed minus the inability of attending to severe chronic conditions such as Asthma, Arthritis, Rheumatism, Diabetes and Epilepsy. Myalgia related to these conditions related to 25% of the cases in this village. Safari Doctors was able to offer simple solutions for pain and symptom relief, then continue to treat a majority of UTIs (16%), Respiratory infections (10%), Parasitic (8%) and Gastric (7%) conditions.

Mkokoni Presentations

Hypertension Respiratory Parasitic

Anemia Dermatology UTI

ENT Injury Gastric

Acute Chronic

5 Kiwayu cha Ndani Village

Kiwayu was the smallest and most remote village we visited, but by far the most in need. There was no building to set up within just a few chairs, a table and some logs under a shady tree. No medical facilities, no medical staff available, a humble traditional village. We handed out mosquito nets, dental care and soap as they were the furthest from these supplies and had limited access to sanitation.

In Kiwayu we saw again many acute conditions, but also potential chronic illness that without our visit may have gone undiagnosed for much longer. For example a little boy with severe asthma suffering from a chest infection was wheezing while he tried to catch up with the other children. We gave him an inhaler to ease his symptoms when required, medicine for his chest infection and some longer-term treatment for his asthma. We also visited a 77 year old gentleman in his hut who was shy to admit he had been experiencing stomach issues and pain. On examination he had a large abdominal mass, perhaps Kiwayu Presentations consistent with a hernia that would need an ultrasound and possible surgery. For someone in this community it isn’t just simple to up and leave your family, for expensive travel and treatment for what could be weeks. Instead of pushing him to go, he was gently encouraged by our doctor to make plans to go and let us know when he might be ready for this intimidating experience. He will be someone that is visited on the follow up outreach and supported by other community health volunteers in the meantime to monitor. Acute Chronic Immunisations

High levels of Parasitic (4&%) and Respiratory (38%) conditions the majority in this village, together with Gastric, Skin and ENT infections normally indicate a Kiwayu Diagnosis possible need for sanitation interventions, relevant to local context (what clean water is available for example, how and where is it stored), and education to prevent future acquired infections. Some of the respiratory causes could be attributed to cooking methods that cause smoke inhalation within the household, therefore for future prevention it may be a requirement for an intervention such as the ‘smokeless stove’ or smoke hoods for open fires. Hypertension Respiratory

Parasitic Dermatology ENT Gastric

6 Siyu Village

Our final and busiest clinic, was serving a community on Pate Island. It is supplied with a keen team staff of nurses and community health volunteers who gladly gave their time and effort to support our clinic. Again this is a community does not have a doctor readily available so the need was still high for the outreach clinic in this location.

Siyu Presentations Siyu Diagnosis

Hypertension Respiratory Parasitic

Anemia Dermatology UTI

Acute Chronic Immunisation ENT Injury Gastric

As illustrated by the charts above, the need for the treatment of acute conditions was high (82%), this included ENT (19%) and respiratory (15%) infections. What were also clearly indicated were significant levels of hypertension, present in 20% of the population we treated. This information is vital to follow up through the careful monitoring of current and potential hypertensive patients. An investigation may be required into why there are significant high levels here and what may be the causes (such as lifestyle choices) that could be prevented through future interventions. There were also many ENT cases, ophthalmology (11%) and dental (8%) issues or infections, of some that required referral and follow up. This is also useful data not only for the communities (to which a feedback session will be provided), and Safari Doctors, but also for the health system in general to be able to prioritize the services required.

7 SUMMARY & RECOMMENDATIONS

Safari Doctors treated a large majority of acute conditions that accounted for 73% of cases. Of July Presentations these acute cases Respiratory (21%), Parasitic (17%), Skin (9%) and Gastric (8%) conditions had the highest prevalence on average over the whole outreach. For chronic conditions, hypertension was the main concern as 12% of the adult population seen by the outreach presented with this issue, this is still reassuringly below the national average, but still requires continuous monitoring and prevention strategies together with the Lamu County Department of Health as the most common cardiovascular issue in Africa. This target, together with heart disease and diabetes, is an important timely focus, as non- Acute Chronic Immunisations communicable diseases are becoming the highest health burden across the world. ANC Family Planning

July Diagnosis

Hypertension Respiratory Parasitic Dermatology

UTI Anemia ENT Gastric

Injury Opthamology Dental Infectious Disease 8 SAFARI DOCTORS JULY REFERRALS

July Referrals

19 in total were made from the July Safari Doctors Outreach Clinic. According to each location and condition will require follow up by the community health volunteers, dispensary staff, the County Hospital and Safari Doctors.

Safari Doctors will be conducting outreach clinic to these communities to ensure this follow up in a smaller outreach session on a TB Gastric Gynacology bi-monthly basis. This will be an opportunity Opthamology Hypertension Dental to share feedback with the communities and strengthen these important relationships. Orthopaedic HIV

FUTURE OUTREACH RECOMMENDATIONS

In moving forward Safari Doctors hope to main a main medical outreach with a full medical team for support every other month. We have established that a minimum team of 7 is required to provide adequate services, with a medical coordinator to direct the operational management. This would include: • 2 clinicians (minimum 1 medical officer and 1 clinical officer) • 1 nurse for triage • 1 nurse for wound care/tests/infectious disease screening • 1 nurse for immunisations/family planning/antenatal care • 2 staff for dispensary (pharmacist and assistant)

9 During the months in between we have recognised the need for referral follow-ups, feedback sessions from the villages and the development of a supportive programme for the community healthcare workers. This smaller outreach session may require the attendance of the medical coordinator, outreach nurse and administrative assistant.

In this clinic we reviewed the use of a triage system, new medical assessment and referral form that allows for more accurate data collection. Resulting from a debrief with the team, we plan to develop operations with the following suggestions:

i. Two experienced doctors may be required for future clinics due to the demand for diagnosis at communities that do not have this level of medical assessment normally available ii. Two volunteers are required at the dispensary and ideally a pharmacist with an assistant to ensure a good quality of service iii. Referral and clinical pathways to guide the medical professionals with appropriate diagnosis and treatment. It allows for clearer medicine procurement according to need and specific medical conditions iv. To investigate the use of rapid tests for the clinic including; Malaria, HIV, HB (to test for Anemia), and BM (Diabetes) v. An operational policy and procedures for the running of the medical outreach clinic vi. Medicine procurement process vii. Guidelines for community feedback viii. Follow up session guidelines for post clinic outreach ix. Develop program for community health volunteer support and community networks for future mobilisation of communities x. Investigate how to continue sanitation interventions (such as chlorine distribution) to prevent future disease outbreak xi. Connect with identified donor for multivitamin supplies to prevent malnutrition amongst these marginalised communities, and possibly for non-communicable disease management xii. Establish a cold chain system for immunisations xiii. Equipment/treatment available for family planning and antenatal care

Safari Doctors also have the opportunity to renovate the Safari Doctors boat to be suitable for the clinical outreach. We hope to have available on the boat and for future clinics: i. Two portable treatment couches for examination and treatment ii. Portable equipment box containing BP Monitor, two stethoscopes, thermometer, Tongue depressors, otoscope set, pen torches, 02 monitor, fob watch, iii. Waste storage for clinical waste and sharps iv. Solar fridge for immunisation storage v. Portable clinical screens to increase privacy/efficient use of space vi. Large cool and secure storage space for medicines vii. Dry storage for treatment box (wound care packs, syringes, needles and sterile equipment)

10 A SPECIAL THANK YOU TO:

v LAMU COUNTY GOVERNMENT DEPARTMENT OF v THE POLLINATION PROJECT awarded a grant to HEALTH is the backbone of Safari Doctors. The Safari Doctors contributing to partial costs of department consistently provides a medical officer clinic operations. and mobilizes respective dispensary staff where present and the community health volunteers. v THE MOON HOUSES has been hosting Safari Doctors from inception and continues to offer v THE VILLAGE EXPERIENCE AND KIDS FOR KENYA unconditional administrative support. funded all travel and medicine for the July and September clinics. v MANDA BAY HOTEL offers reliable support by playing an advisory role and providing consistent v RX CLINIC PHARMACY consistently raises awareness strategic and logistic support. and crowdsourcing options that allow us to cover the basic operations of Safari Doctors such as v ROYAL AFRICAN SAFARIS / ATHONY ROBBINS administrative and communication costs FOUNDATION have been the sole biggest support to date for Safari Doctors. Their contribution v BALLANTYNE FAMILY MEDICINE was a key sponsor allows basic outreach services by the Safari whose contribution allowed Safari Doctors to set on Doctors nurse who will now be able to conduct its inaugural sail of 2016. our monthly outreach for the next year v DOCTORS OF THE WORLD, UK support with a v FRIENDS OF SAFARI DOCTORS make up the volunteer medical coordinator was a critical engine on which we operate. ASANTENI. component in facilitating this July clinic. v CNN HEROES has given Safari Doctors and v INTERNATIONAL FOOD AND HEALTH ORGANIZATION founder Umra Omar a noteworthy platform to (IFHO) and SAFARI GOLF have come on board to raise awareness on innovative approaches to sponsor a full outreach clinic scheduled for the addressing health care gaps in our communities. month of November 2016.

-African Proverb