Thursday, October 25, 2018

When Hospitals Become Jails

The Kenyatta National Hospital is east Africa’s biggest medical institution, home to more than a dozen donor-funded projects with international partners — a “Center of Excellence,” says the U.S. Centers for Disease Control and Prevention. The hospital’s website proudly proclaims its motto — “We Listen ... We Care”.
Robert Wanyonyi, is not allowed to leave the hospital because he cannot pay his bill of nearly 4 million Kenyan shillings ($39,570). At Kenyatta National Hospital and at an astonishing number of other hospitals around the world, if you don’t pay up, you don’t go home. 
The hospitals often illegally detain patients long after they should be medically discharged, using armed guards, locked doors and even chains to hold those who have not settled their accounts. Mothers and babies are sometimes separated. Even death does not guarantee release: Kenyan hospitals and morgues are holding hundreds of bodies until families can pay their loved ones’ bills, government officials say. During several August visits to Kenyatta National Hospital, The Associated Press witnessed armed guards in military fatigues standing watch over patients, and saw where detainees slept on bedsheets on the floor in cordoned-off rooms. Guards prevented one worried father from seeing his detained toddler. All despite a court ruling years ago that found the detentions were illegal. At many Kenyan hospitals, including Kenyatta, officials armed with rifles patrol the hallways and guard the hospital’s gates. Patients must show hospital guards a discharge form to prove they’re allowed to leave and even visitors must sometimes surrender their identification cards before seeing patients.
“What’s striking about this issue is that the more we look for this, the more we find it,” said Dr. Ashish Jha, director of the Harvard Global Health Institute, who was not involved in the British research. “It’s probably hundreds of thousands if not millions of people that this affects worldwide. It is not something that is only happening in a small number of countries, but the problem is that nobody is looking at this and it is way off the public health radar.” The problem has also surfaced in wealthier countries, with patients being detained in hospitals in countries including India, Thailand, China and Iran.
In Congo’s second city of Lubumbashi, the AP visited more than 20 hospitals and clinics and found that all but one routinely detained patients who failed to pay, even though the practice is illegal there.
“It’s the dirty underbelly of global health that nobody wants to talk about,” said Sophie Harman, a health academic at Queen Mary University of London.
“People know patients are being held prisoner, but they probably think they have bigger battles in public health to fight, so they just have to let this go.”
 In some hospitals in Cameroon and elsewhere, for example, the problem of patient imprisonment was solved by some institutions by simply demanding payment upfront. Unlike many hospitals in developed countries, African hospitals don’t always provide food, clothing or bedding for patients, so holding onto them does not necessarily incur a significant cost. Detained patients typically rely on relatives to bring them food while those without obliging family members resort to begging for help from staff or other patients.
Dr. Festus Njuguna, a pediatric oncologist at the Moi Teaching and Referral Hospital in Eldoret, about 300 kilometers northwest of Nairobi, said the institution regularly holds children with cancer who have finished their treatment, but whose parents cannot pay. The children are typically left on the wards for weeks and months at a time, long after their treatment has ended.
“It’s not a very good feeling for the doctors and nurses who have treated these patients, to see them kept like this,” Njuguna said.
“We can’t just let people leave if they don’t pay,” said Leedy Nyembo-Mugalu administrator of Congo’s Katuba Reference Hospital. He said holding patients wasn’t an issue of human rights, but simply a way to conduct business: “No one ever comes back to pay their bill a month or two later.”
In its 2016 financial report, Kenyatta’s auditor-general said the hospital lost more than $470,000 in fees from patients who “absconded” without paying. That year, the hospital reported total revenue of more than $115 million. Kenya’s Human Rights Commission attempted to conduct an audit of Kenyatta, but officials refused to cooperate and have ignored all requests for information about detained patients.
In January, demonstrators called for an investigation into allegations of rape and sexual harassment of patients at the hospital. 
“This is something that hospital authorities have been trying to keep under wraps,” said George Morara, vice chairperson of the country’s national commission on human rights. He said the number of Kenyans imprisoned in hospitals is “disturbingly high” and that the practice is “ubiquitous in public and private hospitals.” He said patients have been held at Kenyatta for up to two years, and it was reasonable to suspect that hundreds of patients could be detained there at any time.
After she was elected to Kenya’s Parliament, Esther Passaris visited Kenyatta last December to check on supporters who were injured in election violence. She was stunned to find that patients were incarcerated.
“There was one lady I met in the corridor and she was crying, ‘please let me go home,’” Passaris said. The woman had hurt her back and hip. She had been medically cleared to leave, but wasn’t allowed to go home because she hadn’t paid her bill. “I just thought, ‘Oh my goodness, it’s almost Christmas, how can these people not go back to their families?’”
Passaris started an online campaign to have the patients released. Just before the holidays, Kenyatta let more than 450 leave — a victory, Passaris says, though the problem remains.
“Unfortunately,” she said, “you can’t get water from a rock, so some of these patients stay for a year because they don’t have the money.”
“Aid money becomes ineffective and useless in an environment where people are terrified they’re going to be locked up,” said Robert Yates, a health policy expert at Chatham House, the British think tank that reported on imprisoned patients. “It’s very embarrassing for the global health community that these detentions have become so embedded into countries that they seem normal, and so the whistle needs blowing on all of us.”
Dr. Carey Farquhar, director of the university’s Kenya Research and Training Center, said she didn’t recall seeing any detained patients at Kenyatta, though was not surprised that it happened — she knew of no hospitals there that did not detain patients. “It does make me uncomfortable,” she said.
Dr. Agnes Soucat of WHO said the U.N. agency was aware of hospital detentions and confirmed they happened “quite frequently.”
“We do not support this in any way, but the problem has been documenting where it happens,” said Soucat, director of WHO’s department of health systems, financing and governance. To date, WHO has made no attempt to collect data on hospital detentions and says such information is hard to find.
Researchers for the Center for Reproductive Rights, which acts to support women’s health around the world, were conducting a study of maternal health care in Kenya in early 2012 when they learned of the cases of Maimuna Awuor Omuya and Margaret Oliele.
Unable to pay her bill at Pumwani Maternity Hospital after the delivery of her sixth child, Omuya and her baby were imprisoned along with more than 60 other women in a damp ward, in September 2010. She often slept on the wet ground next to a flooded toilet. Mother and child were released after nearly a month, but only when one of Omuya’s friends appealed to the mayor to intervene.
Two months later, Oliele arrived at Pumwani. During a botched cesarean section, doctors left a pair of surgical scissors inside Oliele’s stomach; a second surgery was needed to remove the scissors and she later suffered a ruptured bladder and a blood infection. When she couldn’t pay her hospital fees, Oliele was taken to a detention ward.
“I tried to escape, but when I got to the main gate, I was taken by the security guards,” Oliele told AP. “I had no clothes on and still had the catheter in my stomach. The guards then forcefully took me back to the hospital where they handcuffed me to a bed, while claiming that I had gone mad.” She was held for six days.
Center for Reproductive Rights lawyers resolved to take up the cause of detained patients, bringing suit on behalf of Omuya and Oliele.
“These were two very appalling cases and their treatment was very degrading,” said Evelyne Opondo, a senior regional director at the center who oversaw the case.
They won. In September 2015, Kenya’s High Court ruled the women’s detention violated numerous human rights enshrined in the constitution and was therefore illegal. The High Court described the women’s detention as “cruel, inhuman and degrading.” The court further ordered the Kenyan government to “take the necessary steps to protect all patients from arbitrary detention in health care facilities.”
But three years later, it appears little has changed. “People are still being detained,” Oliele said. “They should stop treating people like animals and treat them as fellow human beings.”
Opondo said detentions continue because nobody has asked hospitals “to provide answers, because they’ve not been held accountable.” She estimated there could be many thousands of people across the country detained, based on information received by the center and news reports.

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