Kenyan care
In 2003 when the last article in this journal talked about Kenya, it was introduced with the slogan of the Kenya Tourist Board: ‘Magical Kenya – Experience a different safari every day’. At the time, Kenya was riding on the crest of a wave of optimism following the election of 2002, which was hailed throughout the world as a model of the democratic process in action. A lot has changed since then, but what have the effects been on the treatment of those needing medical attention whilst in the country?
First published in ITIJ 113, June 2010
In 2003 when the last article in this journal talked about Kenya, it was introduced with the slogan of the Kenya Tourist Board: ‘Magical Kenya – Experience a different safari every day’. At the time, Kenya was riding on the crest of a wave of optimism following the election of 2002, which was hailed throughout the world as a model of the democratic process in action. A lot has changed since then, but what have the effects been on the treatment of those needing medical attention whilst in the country?
How quickly time passes
After the 2002 election, there was a smooth transition from the party that had held total power for over 21 years to a loose coalition predominantly on an anti-corruption manifesto. Five years later, the December 2007 election was universally condemned both inside and out of the country, with the European Union describing the election process as badly flawed and failing to meet international standards. In the midst of a reaction against the perceived rigging of votes, over 600 people died and nearly 300,000 people throughout the country were displaced in a little over a week of inter-tribal fighting. Homes, shops and businesses were burnt and looted, and more violence continued to occur over the first few weeks and months of 2008.
Kenya descended from being an award winner of the ‘Best Adventure and Ecotourism destination in Africa’, which subsequently had visitor rates rising from 500,000 to just under a million, to a country subject to travel advisory warnings from international governments – which consequently meant a 35-per-cent drop in its burgeoning tourist numbers. The UK’s Foreign and Commonwealth Office (FCO), the US State Department and similar agencies in other countries issued travel warnings concerning ‘non-essential travel’ to specific areas of Kenya. The term acknowledges that a person may need to travel for business, humanitarian or family reasons. The ‘non-essential’ part of the phrase refers to holidays and leisure activities. While the advice was relaxed on 21 January, just 18 days after it was issued, the country’s tourism industry had suffered serious long-term damage.
Most members of the UK’s Federation of Tour Operators heeded the advice and suspended holiday schedules to Mombasa. Some of these operators – including Thomas Cook, Thomson, My Travel and First Choice – decided to cancel all holidays to Kenya until May 2008. Malcolm Tarling, spokesman for the Association of British Insurers, commented at the time: “If you travel against Foreign Office advice and are injured, insurers could argue that you are putting yourself at extra risk, and they expect you to take reasonable care. Insurance policies are not designed to cover you in what might be seen as carelessness.”
During the times of the post-election violence and the subsequent ‘Go-there-at-your-own-risk’ warnings, not one single tourist was the subject of an attack or was involved in any form of ethnic or post-election violent acts. The disaster and the destruction were confined to the Kenyan people themselves. There was a gradual realisation that the areas that were decreed as ‘no-go’ by the travel advisories were villages, towns, districts and provinces that were far off the tourist track. Slum townships, the scenes of the greatest violence, were never on the itineraries of the casual visitor to Kenya.
Slum townships, the scenes of the greatest violence, were never on the itineraries of the casual visitor to Kenya
Using that fact, together with some extensive and prolonged lobbying, the local tourist agencies and associations brought Kenya back up again in 2009 in the eyes of the travel market. Travel and tour operators at all levels – from the sun-and-safari beach holidays in the coastal areas to the seriously up-market, thousands-of-dollars-a day, high-end visitors – have seen the gradual return of a vital foreign exchange earner. For the last three years, Kenya has seen a steady growth in tourism; back now close to the one million mark of 2007. (In the meantime, local Kenyans queried the lack of travel advisories for the UK, following a series of bombings in London.)
The recession of 2009 slapped Kenya once again. Travellers at all levels held back from spending money. Once more, with extensive lobbying and shrewd marketing, Kenya saw the growth start up again. This time with more visitors in the middle to lower ends of the scale – previously high-end travellers went to the middle level and the middle level slipped down to the beach, sun and safari holidays. But at least they started to return.
In the words of the International Monetary Fund managing director Dominique Strauss-Kahn during a visit to the region in March 2010: “As I’ve said many times in the past, African countries were largely innocent victims of the crisis. Thankfully, the tide seems to have turned and all across the continent, we can see signs of a rebound – in trade, export earnings, bank credit, and commercial activity.”
But at whatever level the traveller makes his temporary home, and this applies equally to the business traveller, the questions come up in their minds, ‘What if … I need to see a doctor/have an accident/need hospital treatment/need to travel back to my home country for more intensive medical care?’
Despite the image of being close to nature and the photographs of tourists watching lions hunting for their supper, attacks by wild animals continue to be a rare event. By far the most serious and common reason for medical evacuation is road traffic accidents. Despite the fact that the most common means of transport in Kenya is by road, Kenyan roads are not well maintained and monitored. This lack of basic repair and maintenance, coupled with reckless driving by motorists and an almost futile attempt by the government to legislate appropriately to minimise traffic accidents, combine to provide one of the leading causes of deaths in the country. Road carnage is alarmingly high, with the number of people who perish in accidents surpassing 300 a month. In 2009, the road accident-related death toll reached 1,953 for the period January to June.
Despite the image of being close to nature and the photographs of tourists watching lions hunting for their supper, attacks by wild animals continue to be a rare event
Public service vehicles are often driven hard and badly, with many drivers travelling enormous distances for long hours without adequate rest. The reduction in concentration and the desire to cover as many miles as quickly as possible can cause reckless and ultimately dangerous driving techniques.
In turn, these are the very vehicles that can involve themselves with the innocent passing tourist mini-bus en route to a four-day safari somewhere in one of the game parks, with resulting carnage and a busload of injured tourists.
So what medical care is available within the area for those helpless victims?
Medical facilities
Under the country’s power-sharing agreement, there are two ministries of health – the Ministry of Public Health and Sanitation and the Ministry of Medical Services. Health issues featured prominently in the manifestos of the two competing parties. However, critics claim the result has been a duplication of bureaucracy and expenditure without providing any discernable improvement in service delivery.
Health facilities in Kenya are either run by the government, mission organisations or private institutions. European-type hospitals, a legacy from the colonial healthcare system, are located in the larger towns. Nairobi boasts two of the best private hospitals north of Johannesburg and acts as a primary evacuation centre for the United Nations staff who operate in other zones, including Somalia, Sudan the DRC and Chad. Between Sub-Saharan and Southern Africa, the only specialised paediatric medical centre is also based in Nairobi – Gertrude’s Children’s Hospital.
In 2003, Aga Khan Hospital in Nairobi became the first hospital in East Africa to be awarded ISO 9001:2000 certification for conforming fully to the International Quality Assurance standards for all clinical, diagnostics and administration and support services of the hospital. The certificate is dependent on comprehensive checks and regular surveillance visits.
A ward bed at the privately-run hospital in Nairobi costs $250 a day. A private room will cost $330 a day and an ICU bed around $356 a day. Executive rooms are also available.
Other private hospitals have similar rates and payment procedures. The Diani Beach hospital in Mombassa accepts payments in Kenyan Shillings, sterling or US dollars. It also accepts Visa and Mastercard and travellers cheques. Payment by these methods though is only required if an insurance company has not guaranteed payments or if a patient is not insured. Its room rates per day range from $256 up to $480 for intensive care. In common with other private hospitals these are just the ‘hotel’ elements in hospital charges, with doctors’ fees, procedures, medicines, diagnostic costs and food all on top.
While reasonable quality medical facilities exist in centres such as Nairobi and Mombassa, in other areas, the standard of medical facilities throughout Kenya varies considerably. The more remote an area the less care is available and access to medical evacuation services is vital.
The coastal areas, which have a vast influx of visitors from all over the world, have belatedly started to offer facilities that can deal with ‘normal’ tourist-related illnesses and injuries. Many of these will happily accept the patient’s own credit card as a payment facility, but a large number of them are very wary of accepting an overseas insurance or assistance company’s guarantee of payment, leaving the patient with the problem of a large outgoing cost that will have to be subsequently reclaimed from the travel cover policy. Local knowledge and the ability to facilitate matters can relieve so many of the burdens that can affect a patient or client.
By far the most serious and common reason for medical evacuation is road traffic accidents
The private health sector caters mainly for the wealthy, the tourists and the expatriate community, who either have health/travel insurance or can afford to pay US$100 per day for a ward bed, $320 per day for a private room or $450 for an ICU bed per day, with an initial deposit of $3,000 to $5,000 on admission.
The possibility also exists for fraud, sometimes with the collusion of the policyholder, but often started by just presenting the patient with a bill for ‘tests’ and ‘treatments’ that may or may not have even been carried out, but have attracted a huge invoice. The client pays up using their own means, and the battle is then engaged between the clinic and the insurance company to reduce or at least justify what can be an exorbitant invoice.
Elsewhere, medical facilities in remote areas are few and far between and are generally poorly equipped. It is likely that some Good Samaritan, believing they are doing the best for the injured, will load the victims on to the back of a pick-up truck and shuttle them to the nearest medical facility. The word ‘hospital’ or ‘clinic’ is often used to describe such a place, often giving European/US-based insurance companies a false impression of the facilities on offer to the injured. After that, the requirement will come to move the patient/client to somewhere with better facilities for treatment and/or recovery.
Within Kenya, only a handful of organisations are involved in the provision of emergency medical services (EMS). Of these, the specialised insurance providers cater only for their members, while the public service providers such as St John’s Ambulance are poorly funded and under-equipped.
On the African continent, professional air ambulance services are still scarce, with only a handful of providers operating out of South, West and East Africa.
Care in the air
One air ambulance company that does serve the African continent is AMREF Flying Doctors, based in Nairobi, which probably plays the most important role in the pre-hospital EMS set-up of Kenya and the neighboring countries, in particular because of its professional and high-standard service, which is available not only for its members but for anybody in need, including the poor. It is the largest and one of the best-known flying doctor services in the region and provides medical emergency and trauma care to the sick and injured, and air ambulance transfers between medical facilities.
AMREF Flying Doctors (FD) is the airborne medical services arm of AMREF, the African Medical and Research Foundation, an international non-government health organisation founded in Kenya in 1957. While AMREF’s priority intervention areas are focused on Malaria, HIV/AIDS, family health, water, sanitation and training and health learning materials, the Flying Doctor service is its airborne medical services arm. AMREF FD supports the Clinical Outreach Programme by regularly flying specialist doctors to over 150 remote hospitals in East Africa for patient consultations and specialised surgery. It also provides charity evacuation flights to patients in need. Any surplus generated through the air ambulance service goes towards the Clinical Outreach and the charity evacuation programmes.
The need for air ambulance services has been there for as long as AMREF FD has been in East Africa, but demand is increasing with more people being able to afford such an expensive service. Air ambulance services are provided locally, regionally and internationally, evacuating patients to Nairobi, other destinations on the African continent or intercontinentally to Europe, Asia and the Middle East. The services also include medical escorts on commercial airlines worldwide and the provision of ground ambulance services in Nairobi and other destinations where AMREF FD is able to subcontract a reliable service provider.
Patients are brought back to Nairobi or repatriated to their home countries not just from within Kenya, Tanzania and Uganda, but indeed from all parts of the world. The company’s 24-hour control centre is equipped with many means of communication to help to make it possible for that first essential call to get through: telephone, fax, mobile phone, satellite phone and fax, HF radio, email/Internet. HF radio, however, is still one of the most useful means of communicating with remote areas in Africa. Most police stations and missions have radios and once installed it is to all intents and purposes free to use, and is reliable. HF/email links are now also possible and gradually becoming more widely available.
Assistance services
Dr Bettina Vadera, the medical director of AMREF FD, says: “We are the only air ambulance service that owns and operates its own fleet of aircraft with blanket flight clearance into neighbouring countries that has full-time medical staff, the radio network and most importantly the local knowledge to work in the region.” The company is, thus, ‘acting more and more as a service provider for European and American medical insurance and air ambulance companies’. “We can get their clients out of trouble quickly and safely and bring them straight to Nairobi’s modern health facilities and then, if need be, help send them home or transfer to a specialised centre elsewhere,” commented Dr Vadera.
Assistance services are mainly provided to international insurance and assistance companies. Acting as their local agent, AMREF FD liaises with hospitals and medical consultants on behalf of the insurance company; places payment guarantees where required; and is able to arrange accommodation, air tickets, ground transport and other services for insured clients, including funeral assistance and the repatriation of human remains. Where necessary, the company works through professional sub-contracted service providers like travel agencies or transport companies. Such assistance services are provided against a file fee.
Nairobi boasts two of the best private hospitals north of Johannesburg and acts as a primary evacuation centre for the United Nations staff who operate in other zones
From a local organisation specialising in bush airstrips and evacuations from remote areas to Nairobi, the EURAMI-accredited AMREF FD service now uses 10 aircraft – three Citation Bravo jets, all fitted with twin LifePort stretcher systems; four Beechcraft King Air B200 aircraft; and three Cessna Caravan 208B’s, allowing safer evacuations over both short and longer distances.
Communication and infrastructure
Ordinary fixed-line telephones are simply not available in most areas and to most people, and even in urban or semi-urban areas work poorly. People in Europe may find it hard to imagine having to dial 10 or 15 times to make a call go through. Or maybe that a call will never be made, if the lines have been stolen.
It is still true, however, that the poor communications infrastructure often delays the start of evacuation efforts. Recently, a light aircraft carrying three tourist passengers to Tanzania to a game lodge crashed in high winds. The crash was seen by another aircraft, whose pilot alerted the Tanzania air authorities; they in turn contacted the Kenya Airports Authority, who then called AMREF FD to assist. This chain of communication, though rather tortuous, did work, but it was slow, and the air ambulance was lucky to be able to take off with just enough time to land near the crash site in the last of the daylight.
Outside the main cities, airstrips are often minimally equipped, and often in very poor condition. AMREF FD maintains its own database of information on many hundreds of bush airstrips, so that if called to one they know that, for example, the bush grows close to the strip and they may need the high-winged Caravan to be able to land; or that last time there were numerous potholes that the local community was asked to repair and that this must be checked before flying in again. Almost none of these airstrips have any radio communication or lighting; most even lack a windsock.
The Tanzania air-crash rescue mentioned above required landing on just such a bush airstrip. As the evacuation flight had only set out in the afternoon, by the time the patients had been given first treatment and were ready for take-off to Nairobi, night had fallen and the airstrip was completely dark. The pilot had, however, arranged for some vehicles to come to the airstrip, and was satisfied that he could take off safely in the light from the headlights. All went well and the passengers were in their hospital beds in Nairobi before midnight.
Travel insurance
Another important market for evacuation services and subscription products is the tourist industry in East Africa. For the last four years, Kenya alone has hosted over one million tourists every year.
The majority of visitors will carry some form of medical insurance or travel assistance cover, which is for the most part arranged through their travel agent. (Although it is still surprising how many people launch themselves off in to the third world without a care or thought for the ‘what if?’) Subsequently, business travellers and tourists to Kenya in need of air evacuation or repatriation to their home countries are usually covered as part of their travel insurance policy.
The travel insurance industry in Kenya works through a network of appointed service providers and compensates on a fee-for-service basis. As an extended service, insurance and assistance companies contract other agents to assist and follow up their clients locally. Some agents do not know of the high standards of care that are available within the country, or are not aware of the difficulties that are inherent in operating in Africa. They may not appreciate the time constraints that can exist when the evacuation of a seriously ill client has to be considered. Some of the policies do not provide sufficient funds to cover the cost of evacuation, hospitalisation or repatriation. It could be argued that it is up to the customer to arrange sufficient coverage. But it could also be pointed out that it is up to the agent to realise how expensive such facilities can be and to ensure the client is given the best possible advice and support.
A question of time
In one incident, a family based in the Chyulu Hills – some six hours by dusty, poor quality road from Nairobi – called AMREF’s 24-hour Emergency Control Centre. Their child, aged three and a half, had been vomiting with diarrhoea for two days, and some locally obtained medication had not produced any result. By the middle of the third day the child was drowsy and lethargic, and could take no fluids. The family realised that she must be taken to Nairobi immediately. The long and uncomfortable road journey would be too slow, so they requested an air ambulance.
While the flight was being prepared, the family’s insurer in Europe was contacted and the usual procedures were set in motion. By mid-afternoon in Kenya, the child was now unresponsive, and unfortunately so were the insurers – they promised that the case ‘was being reviewed’, but no decision was forthcoming. The pilot finally stated that unless the flight took off within 20 minutes it would have to be delayed until the next morning.
At this point, the family decided that action was essential and offered their own guarantee for the flight payment. The aircraft took off and collected the small patient and her family. On arrival at the Nairobi hospital it turned out that the parents’ instinct had been right – their child had a serious gastro-intestinal infection and could easily have died in the night if they had not had her flown to Nairobi for treatment. There had been more good news: about half way to Nairobi the pilot was able to tell the parents that the insurer had called and that he was now authorised to take off.
Pre-planning
Progressive thinking by the more astute safari companies can help to maintain the support and feeling of comfort required by travellers. One example of pre-planning and use of local resources comes from a recent scheme set up by Private Safaris, the business unit of Kuoni Destination Management in Africa and one of the continent’s leading destination management companies. A plan by Private Safaris to increase clients’ safety while on a safari resulted in the decision to go into partnership with AMREF FD. The goal was to facilitate medical emergency care and evacuation services to all of its clients.
Thomas Iten, executive director for Private Safaris East Africa commented, “The provision of this medical package met the high international emergency care standards set by Private Safaris for their clients. Given that many tourist destinations in East Africa are situated in remote regions and provide limited medical facilities, AMREF FD were an ideal attribute to the existing safari tours in Kenya, Tanzania and Zanzibar. AMREF’s control centre administers communication and overall logistics. Its doctors and nurses are on call around the clock.”
The private health sector caters mainly for the wealthy, the tourists and the expatriate community
The Kenyan Government has also realised the importance of working with the tourist industry and officially implemented a Tourist Crisis Response Committee, which meets both regularly and on demand to co-ordinate and control actions and reactions to any incident that affects the travelling public. It includes representatives from the Tourist Police Unit, the travel and tourist industry, the Kenya Wildlife Service, the Kenya Tourist Board and the Kenyan Tourist Federation – who also run a 24-hour tourist emergency response system. Recognising the importance of the AMREF FD service, the government also appointed AMREF FD’s medical director as a Gazetted representative on this committee.
The sheer size of Kenya can present problems. It is a country still blessed with huge tracts of land where there are no towns, cities, or facilities such as fuel supplies, and the planning of each trip requires detailed local knowledge. It has to be always borne in mind that if things do not work out as expected, there are few or no support facilities to help put things right. But it’s a great place to live, work and have a holiday!