I often ask myself the same question.
We are supporting the Kenyan Ministry of Health’s policy to improve the management of chronic non-communicable diseases (NCDs – hypertension, diabetes, asthma and epilepsy in the first instance) in rural clinics and health centres. Before we started work in Embu in August last year, most people with NCDs went to the local district hospital for treatment or attended a private clinic. We think that highly trained doctors working in hospitals should be treating more complicated conditions, and leave the simpler stuff to primary care. If this scheme is implemented throughout Kenya, it will save the Ministry of Health billions of shillings.
Eleven months later, almost 2,000 patients with NCDs receive their treatment at their local health facility, where local health workers have not just been trained, they have been mentored to improve their knowledge, skills and attitudes.
The usual approach to training rural health workers is to get funding from an aid agency to run a course in a hotel conference room. After eight hours of death by PowerPoint, the health workers get a certificate and are considered trained. We are using a different approach, mentoring.
Our 12-strong team of highly trained clinical officers, nurses and health promoters have been trained to mentor health workers in five rural health centres and two dispensaries. The cycle lasts for six months, with weekly visits, a structured learning programme, one-to-one teaching, observation of clinical practice, etc. The mentoring team uses a set of disease-management guidelines which have been specifically designed for rural Kenya. These can deal with over 90% of the patients we see, but when the guidelines don’t seem to fit, the mentors ask for advice from the expatriate doctor.
All that wheezes isn’t necessarily asthma.
The mentor asked me about a 65-year-old lady with rheumatoid arthritis who had a year-long history of expiratory wheeze, nocturnal dry cough and chest tightness. She said she had cooked for years using dried cow dung in a restricted kitchen area. She didn’t smoke, but her husband had done in the house for years. A few months ago, she had started taking 10mg prednisolone (steroid tablets) for arthritis, which had helped to improve her wheeze. The steroids were stopped and her wheeze came back.
Examining her she had widespread expiratory wheeze. Her peak expiratory flow doubled after salbutamol inhalation. I concurred with the mentor that the diagnosis was adult-onset asthma, which is pretty rare.
Contrast this with a 45-year-old man who had attended the health centre with shortness of breath and a cough a week previously. The nurse (not on our programme) had treated him with two different intravenous antibiotics, oral antibiotics, salbutamol tablets and antihistamines. The nurse had diagnosed asthma and asked him to come for review when the team attended.
On closer questioning, the patient said he was feeling much better. He had similar episodes once every two or three years. Clearly, this was a chest infection, not asthma, as the unmentored nurse had thought.
Another lady with a 20-year history of asthma treated with salbutamol tablets (we stopped using these in UK general practice when I was in medical school) had enrolled in our NCD programme a month ago. She had been prescribed a reliever (salbutamol) and a preventer (steroid) inhalers instead of tablets. She told us that she had only had one attack during the past month when she had been caught in the open by a cold rainstorm while she was farming. It became apparent that she had been using the steroid for relief and the salbutamol for prevention (the wrong way round). Still, even so, she felt better. She will improve even more when she uses the inhalers properly.
It is really important to spend time with patients to understand how to use their inhalers. We don’t have any placebo inhalers to demonstrate technique (I am working on this). When observing our mentor in the consulting room, I saw one lady who managed to use her salbutamol inhaler upside down. When she eventually managed to fire off a dose, the gas was unable to get out of the closed mouthpiece and came up alongside the aerosol canister for her to inhale.