The wheels of my suitcase were the only audible noise in the corridors of Kenyatta National Hospital. On our first day in Nairobi, as we made our way through the clinics to the lecture hall, a shortcut led us to the Accident & Emergency (A&E) Department. Preceding our trip, we had heard stories about the A&E department for months. As an emergency physician, I was interested in seeing how the internists who staff the A&E–without formal emergency medicine training–handled the most critical patients. However, on this morning, day 38 of a countrywide doctor’s strike, the A&E was a skeleton of its usual self. There was just a spattering of military paramedics in full fatigues, with assault rifles strapped to their backs, performing basic suturing and first-aid. Similarly empty were the operating rooms, medical wards and the medical school campus at Kenyatta National Hospital. An identical scene was present at every public-sector hospital across the country.
An estimated 5,000 members of the Kenya Medical Practitioners and Dentists Union (KMPDU) who work in public hospitals across Kenya went on strike on December 5, 2016. This was a result of broken promises made to physicians in the 2013 Collective Bargaining Agreement (CBA) by the Kenyan government. This agreement promised that the government would provide physicians improved work environments, allowances for paid/unpaid leave, a research fund, insurance coverage, safety regulations, hour restrictions, over-time wages, and improvements in medical equipment. The CBA ensured 400 new residency positions and the recruitment of 1,200 physicians a year for four years in order to offset Kenya’s dismal physician-to-population ratio, which is at best estimated at 1:5000. Most notably, the physicians were set to procure significant (300%) raises, totaling a minimum gross wage of Kshs 447,000 ($4,300 USD) and Kshs 1,276,000 ($12,500 USD) per month for the lowest and highest paid doctor, respectively. The CBA, was agreed upon on June 27, 2013. It was expected to be enacted on July 1, 2016, but this was never carried out by the government. After five months of warning, the KMPDU took to the streets in protest of this failure.
The union’s distrust of the government is not without reason. The Abuja Declaration, established between African Union countries in 2001, pledged to set a target of allocating at least 15% of their annual budget to improve the health sector. Kenya’s current allocation is 2.7% of their total annual expenditure. In 2016, a leaked internal audit surfaced revealing a quarter of the 2015 national budget ($4.4 billion USD) went unaccounted for, with over $50 million of that sum coming from the national health ministry’s fund. In addition, during the three years leading up to the strike, the Kenyan government repeatedly voted to raise their own annual salaries and benefits, with legislators reportedly making up to $14,000 USD per month.
Further widening the chasm between the two sides are the transgressions of the Kenyan government since the strike began: threats to hire scab physicians from other countries, failed “compromise” deals with the union at a fraction of the original agreement, and even imprisonment of seven KMPDU leaders. Many newspaper articles have taken the stance that the Kenyan people are suffering, while the “greedy doctors” demand higher wages. All the same, it is difficult to imagine truly unbiased coverage by media outlets, which are strongly influenced by government leadership (who happen to be up for re-election on August 8, 2017). Social media is even playing a role, as the government has been accused of paying fake bloggers to create the trending hashtags “#greedydoctors” and “#mybaddoctorexperience.”
Strewn amidst the contention are the patients, quietly dying outside of the forty-seven empty Kenyan public hospitals that normally provide care for the majority of the country. There are countless stories of young women dying from pregnancy-related complications, cancer patients’ health deteriorating because of missed treatment sessions, and prescriptions that are unaffordable outside of the unionized hospitals. Without emergency services running in the public sector, critically ill patients are left to watch their disease processes play out unless they are among the minority who are able to afford care at private hospitals. The private hospitals, many of which have facilities that rival our own hospitals, are running normally, staffed by physicians who are largely unaffected by the strike. These facilities, capable as they may be, are not affordable to most Kenyans, and are now experiencing critical levels of crowding due to the affluent patients who have switched out of necessity.
These physicians are overworked, underpaid, and forced to practice medicine in conditions that would frustrate the most altruistic of us in the U.S. Our work in Nairobi introduced us to many remarkable interns and students, who have united in solidarity to support the KMPDU even though their training has been disrupted and their career trajectories are in question. The current situation has left many in the union feeling voiceless, wondering if the desired reconciliation is worth the incurred injustices. And yet, they persist. They continue their fight for the rights of their patients and each other. Faced with the threat of imprisonment and losing what savings they have, instead of seeking work abroad, they peacefully march on. These protesting Kenyan physicians are truly inspirational. These stalwarts have taught me a great deal about resilience and fighting for what is right when your principles are in jeopardy.
A physician once told me that practicing medicine in East Africa is like “trying to eat soup with a fork.” It is a simple enough analogy, yet this “one step forward, two steps back” theme can be seen in many facets of healthcare in the U.S. as well. On the eve of our arrival to Kenya, over forty million people were without access to care because of the strike. That same day, the United States Senate voted to begin the repeal of the Affordable Care Act, which has provided insurance for twenty million people since its rollout.
On March 14, 2017, day 100 of the strike, the government and union agreed to increased wages in exchange for a return to work for the physicians while negotiations continue regarding the rest of the CBA. Conversely, our leadership in the U.S. has proposed the American Health Care Act, which would have implemented substantial cuts to Medicaid and subsidies that help earners making less than $40,000 a year in efforts to cut the national deficit. An estimated 14 million people would have lost insurance in 2018 under this new plan. As of mid-April, the current administration has been unable to pass this version of their healthcare act.
Aside from healthcare reform, the current administration has proposed a $5.8 billion cut to the National Institutes of Health budget, which funds scientific research in the U.S. This, along with overwhelming disregard of facts by our current administration, led to over 500 cities across the world hosting rallies in support of science on April 22, 2017.
The political climate and rhetoric on Capitol Hill, now more than ever, demonstrates the need for effective leadership to represent the best interests of our patients. It is not a fight for our own quality of life that is needed here, but for those we treat.
In the years to come, we will need physicians, scientists, policy-makers, and hybrids thereof to lead a concerted effort to grow the voice of our disenfranchised patient partners. If those of us who represent the voiceless through advocacy need inspiration and strength in the face of the challenges ahead, let us look no further than the resiliency of our Kenyan colleagues.
John Purakal, MD, MSc
Chief Resident Physician
University of Illinois – Chicago
Department of Emergency Medicine
Alixandra Purakal, MD
Chief Resident Physician
University of Chicago
Department of Radiology
1 Density of physicians (total number per 1000 population, latest available year). (2017). World Health Organization. (Accessed March 16, 2017, from http://www.who.int/gho/health_workforce/physicians_density/en/)
2 Signed CBA. Kenya Medical Practicioners, Dentists and Pharmacists. (2017). Kmpdu.org. (Accessed February 2, 2017, from http://www.kmpdu.org/documents/1/49/signed-cba)
3 The Abuja Declaration: Ten Years On. (2017). World Health Organization. (Accessed March 16, 2017, from http://www.who.int/healthsystems/publications/abuja_declaration/en/)
4 Peralta, Eyder. The Doctors Aren’t In At Kenya’s Public Hospitals. (2017) NPR.org. (Accessed February 2, 2017, from http://www.npr.org/sections/goatsandsoda/2017/01/05/508369378/the-doctors-arent-in-at-kenyas-public-hospitals)
5 Kenya doctors end strike after signing government deal – BBC News. (2017). BBC News. (Accessed March 16, 2017, from http://www.bbc.com/news/world-africa-39271850)