Access to Chronic disease care in Ethiopia is so poor that patients who present usually may be quite advanced with one or several complications that result in major disabilities. As a consequence of this Palliative care is becoming increasingly important in Chronic care. Training in Palliative care skills at hospitals in Addis Ababa in collaboration with Hospice Ethiopia is one of Dr Yoseph's contributions at the Ministry of Health, which is not expected to expand to hospitals outside Addis Ababa as well. We delivery training to physicians and nurses to be able to manage pain in patients with chronic disease.
A.F. is a 30 years old woman who was diagnosed with Kaposi sarcoma related to immune-compromising disease. She has developed severe neuropathic pain and was shouting day and night with severe pain. She was referred from the eastern major town of Harar. She travelled with a devoted husband who went to any lengths, even if traveling 500 km to the capital Addis Ababa. The couple had to travel with their 3 years old son, as there was no one to take care of him. After few days of focused pain management with round the clock administration of adjuvants pain was well controlled she went back home to follow up.
The vision of empowered nurses, acting as leaders to realize the ideals of ‘access of care to the rural poor’, is a compelling one. We started to recruit appropriate nurses to lead this effort in three health centres: Shebe, Agaro and Asendabo, each of them located about 50 kilometres south, west and east of Jimma University Hospital respectively.
While recruiting, we also began advocating for THET to support a rotating fund, providing essential medicines and to address the universities mandate and lack of involvement in health care. We quoted the social accountability article of the universities vision and mission statements, that they aim to make to research an entry-point to further health care training and that providing quality service to patients (subjects) and the training of nurses (data collectors) are an ethical requirement of the institution.
Funding for training, coaching, mentoring, supervision and transportation were mobilised, yet again, by THET.
Epilepsy: Burns are one of the major causes of disabilities due to epilepsy. It is a sad fact that many epileptic patients face the danger of falling into open fire made for cooking or other reasons. Falling from on high while collecting twigs for firewood and drowning in the rainy season in the flooding rivers are some other causes of major disability and death. Here are three stories which describe the effects of such epileptic incidents.
A 30 year old lady from rural part of Jimma who developed hand deformity of the fingers and hand following fall into fire while cooking. She remained unmarried and shunned by her family as a burden.
A 21 year old shepherd who had made a bone-fire in the field to warm himself in the cold season while herding cattle had sudden attack of seizure. Fortunately only his hands fell into the fire while the rest of his body was safely away. It was too late when he was discovered and his left hands were burned beyond recovery and amputated while contracture couldn’t be prevented on his right hand. He is currently unable to use his hands.
A 16 years old school girl who fell into open cooking fire while helping her mother, who supports the family selling Injera. The mother was around to take her out of the fire but not soon enough to avoid severe burns to the face. After recovery with a very scarred face, the girl refused to go back to school for fear that her looks would frighten off younger students and also bring her stigma among her peers. Her chances of education and forming a family when coming to age all gone together. She continues to live with her mother
Such tragedies can be effectively prevented through early detection, control of seizures with anticonvulsant drugs and health education. After injury a quick and appropriate burn management and Rehabilitative measures for those who have developed serious disability would also be crucial. Decentralization of services through training of nurses in the primary care setting which are far more accessible to the victims in terms of distance would give the opportunity for early detection and control of seizures and when this has failed an early burn treatment and referral in severe cases will significantly reduce the burden of permanent disability to these patients.
Mentoring and hands on training to health centre nurses
The attached picture shows mentoring and training on the prevention and care for the foot in a 50 year old Type 2 diabetic lady being conducted by health centre nurses.
The training is taking place at the Koladiba health center, in the southwest Gondar area, in northern Ethiopia. Many diabetic patients still present at the centre with complications of diabetes such as advanced retinopathy (resulting in serious compromise to their sight), hypertension and foot ulcers at various stages. Techniques in careful follow up and regular examination of the foot, as well asteaching patients how to observe changes on a daily basis, comprise some of the training provided to health centre nurses during supportive supervision and mentoring visits by physicians and senior nurses from Gondar Teaching Hospital. If such messages are not delivered by nurses to empower patients on how to protect their feet, patients may neglect small wounds which in turn result in severe infection. If neglected, such infections can progress to gangrene and loss of the limb.
All patients with Type 2 diabetes are also referred to Gondar chronic disease clinic where retinal photographs are taken to screen for retinopathy, and where referrals are made for laser therapy to mitigate advanced damages to the eye. Picture 2
Our health care workers feel very sad when they see a child or a young adult with Rheumatic heart disease, which is by far the commonest cause of death and disability from heart disease in young Ethiopians. Of course there are other significant conditions which affect the heart and circulation in Africa, for example hypertension and cardiomyopathy, but these affect adults. An infection in the throat with a streptococcal bacterium is followed, in some people, by rheumatic fever and it is the body’s reaction to the organism which initially damages the heart. Thus the heart will be further damaged if there is another infection.
The teams of nurses and health officers at health centres know that there is little that can be done for some of their young patients because the rheumatic process has damaged the valves of their heart beyond repair; they need very advanced cardiac surgery and it is not yet available in Ethiopia. But they also know, as a result of the targeted training that we give them, that it is possible to prevent recurrences of rheumatic fever if penicillin is given every 3 or 4 weeks to children and young adults who have established rheumatic heart disease.
As care of rheumatic heart disease has now been decentralised to health centres through our programme, our nurses are wonderfully positioned to do basic prevention of infection through regular penicillin. It is they who will keep giving the monthly injection. Here a young girl has become unable to go to school and is bed ridden because of severe rheumatic heart disease. She lives almost as if she has a ‘death sentence’ over her head.
The community can be protected from this fatal and disabling disease through decentralization of care to frontline health providers who detect and treat streptococcal sore throat. Decentralization also helps nurses to detect and refer cases who must first be fully assessed before the year on year of penicillin prevention is begun.
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