Impact of Covid-19 on older people in rural Kenya
Dr Tarun Solanki is a Consultant Geriatrician at Taunton and Somerset NHS Foundation Trust and National Council Chair of BGS England. He has been involved in geriatrics for almost 30 years with a broad range of experience in the speciality.
There has been a significant focus on the impact of Covid-19 on older people in the United Kingdom. It is clear that in the UK older people have been disproportionately affected both in terms of the number of deaths and the impact of social isolation, de-conditioning and delayed diagnosis of other conditions. While it is important for us to focus on the issues facing older people in the United Kingdom, it is important for geriatricians to have a broader perspective of the impact of this pandemic on older people in countries which do not have the benefits of the health care and social care available to us in the UK.
Earlier this year, I had the opportunity to visit a rural village in Western Kenya to see first-hand the plight of older people. I was based at Ramba village which has a population of approximately 4000 with just over 200 people over the age of 60 and 80 people over 80 years old. The residents are of the Luo tribe, accepted nationally to be one of the poorest tribe in Kenya’s diverse population with a poverty level of 52.9% compared to a national average of 36.1%. Furthermore, the County has an HIV/AIDs prevalence of 27.1% compared to the national average of 6.3%. Socially the county has a huge burden of care for a large number of orphans; widows and widowers as both parents and spouses suffer due to HIV/AIDS. The county has a doctor to population ratio of 1:40000 and nurses at 1:1500. These statistics relate to whole populations and it is generally accepted that poverty and inadequate health care provision disproportionately impacts the old and children. In the absence of state provision, older people have to rely on savings, occupational pensions (very rare) or on relatives for support if they are unable to sustain themselves. The majority of villagers rely on subsistence crops of maize, sweet potato and kale for their meals. Even if, as an older person, you are fortunate to have working age children they cannot be relied upon to provide for food and support as the children themselves have barely enough to feed themselves despite working comparatively long hours for a pay equivalent to £1-1.50 per day. Frailty, illness or disability leaves the older person vulnerable to malnutrition or starvation as they are unable to tend the land, look for firewood and obtain water from the local bore hole. As mentioned above, access to health care is very limited and frequently inaccessible to the older population due to the extreme poverty.
During my visit I saw over 30 frail old people over the age of 80, both on domiciliary visits and a clinic of 12 patients. The common threads with these individuals were lack of food, loneliness and lack of finance for even simple medications such as paracetamol! All of them were underweight with most weighing less than 50kg. My ordinary sphygmomanometer cuff was too large for the majority. The most common medical complaint was of joint pain from significant osteoarthritis in their hips and knees. Despite this they were all mobilising with a stick or unaided. I lady I met was a 96-year-old lady living in a remote location (we had to walk the last 500m despite being in 4WD vehicle). She was blind in one eye and was complaining bitterly of a painful left wrist following a fall a couple of months ago. She had not sought medical help for lack of money. She continues to have severe pain in the wrist and cannot use the left hand/arm due to pain. Consequently, cooking has been difficult and on one occasion when she was cooking her only dress got burned.
On examination her left wrist was deformed and fixed in a partially flexed position. It looked as though she had sustained a distal radius fracture a few months ago. If someone with some medical advice was available, the wrist could have been splinted relieving the pain even if the fracture had not been reduced. For her the solution was simple – splint the wrist, paracetamol 500mg (she weighed less than 30kg) and a square meal. She did not have money to buy proprietary paracetamol and generics are more often than not fake.
It was apparent that many of the older people were isolated, lonely and malnourished. One way of relieving this is to have some form of day care facility where these older people could have a square meal, a wash and have social contact with other people. In fact, the Regional Plan for the County states “There is a need to increase funding programmes which target the aged such as cash transfer programmes aimed at cushioning this group of people from the effects of escalating poverty and neglect. It has been suggested that homes for the aged should be established to cater for the extremely vulnerable ones. Facilities that address health care and recreation for the aged will also need to be considered.” While the regional plan is laudable, it is likely that other pressing priorities have taken precedence.
In addition to the pressures faced by these older people every day their problems have been compounded by lock down curfews and heavy rainfall resulting in loss of homes. The Guardian reported on 13th May that almost 200 people have lost their lives and 40000 have been displaced from their homes in East Africa particularly around Lake Victoria. According to Reliefweb’s Kenya situation report from 29th May, the Covid-19 pandemic is occurring against a backdrop of increased humanitarian needs due to back to back drought, floods and locust upsurge is exacerbating vulnerabilities across Kenya, particularly for the urban poor. So far there have only been 62 reported deaths from Covid-19, however, the intense rainy season has affected 59,032 households (301,851 people), including the displacement of 42,329 households (211,465 people). As a consequence of Covid-19 imposed restrictions of movement and the heavy rainfall, maize prices in urban reference markets ranged from 11 to 22 percent above the five-year average. Women and older people are bearing the brunt of this adverse impact. Food insecurity remains a major issue with 74% of those surveyed missing a meal in May.
Even prior to the pandemic, older people were at greater risk of food insecurity and this has been exacerbated by the current crises. Older people in rural communities are more likely to die from starvation and the after effects of the flooding than from Covid-19 infection.
Whilst we grapple with how to return to normality from the pandemic and how we can begin normal services for older people in the UK, it is important to remember that for many older people in rural Africa, it is still the lack of basic necessities such as food, shelter and sanitation which lead to excess deaths. As a society we need to address not only the inequalities apparent in our own country but also those in developing countries. Minor individual and corporate sacrifices in the UK can result in dramatic improvements in the quality of life experienced by frail older people in many developing countries not just in Kenya. For example, sacrificing one coffee from your favourite coffee shop would support one older person in food, clothing and basic medicines. For a corporate organisation, a £1000 annual donation will support one older person for almost a whole year. There is a role for Societies involved in the welfare of older people in the UK, Europe and the USA to advocate, support and enable the local/regional plans for older people to be realised.