Jocalyn Clark (@JocalynClark) describes the challenge of achieving and maintaining basic cleanliness and sanitation in a children’s cancer ward in Dhaka, Bangladesh.
A couple of years ago I wrote about a talk Wendy Graham gave at the Maternal Health conference in Arusha, where PLOS Medicine was launching its Maternal Health Collection. I found the talk startling. She raised troubling questions about the global push for institutional births when facilities in many regions are ill-equipped, unclean, under-staffed, and otherwise inadequate to meeting women’s needs. Why focus so much on facility interventions to reduce maternal deaths when the settings (hospitals or clinics) themselves lack the basic hygiene and sanitary conditions necessary to achieve intended health outcomes?
The notion of hygiene as such a basic determinant of health hadn’t quite hit home for me until her talk. Since then there has been slowly growing recognition of how essential cleanliness and sanitation are to healthcare, including a recent call to action in PLOS Medicine to join up the WASH (water, sanitation, hygiene) and maternal health sectors in the new post-2015 development agenda.
I was reminded of this hygiene-healthcare link this past year when I began volunteering at a children’s cancer ward in Dhaka. To put it bluntly the ward was filthy. During a bi-monthly volunteer clean-up day, it literally felt repulsive. Feces on the walls. Cockroaches and discarded syringes on the floors, dirt and stains on beds and sheets. Toilets barely approachable. In fact, a big focus of Dhaka Kids With Cancer, the charity helping improve care for the children on the ward, has necessarily been on cleanliness and hygiene. When the charity first launched here in Dhaka, they recognised massive needs around training of medical staff to ensure best clinical practice and of purchasing medicines and chemotherapy – they’ve recently received funds from World Child Cancer to help do so. But the charity also recognised early on that they wouldn’t get the desired improvements in health outcomes without immediate improvements in hygiene.
A first priority involved cleaning up and maintaining the physical space – there are now fewer cockroaches, regularly replenished supplies of soap and sanitiser, and regularly cleaned beds and floors. Basics like mattresses and cabinets were purchased, as well as dedicated bins for separate disposal of food and medical waste.
The cleaning staff, viewed by many as the lowest status of all workers on the ward but nonetheless vital to ensuring hygienic space, were in particular need of attention. They required not just training and better and more abundant cleaning supplies, but encouragement that their work mattered, says Karen Ryder a British expatriate trained as a nurse who has been spearheading efforts on hygiene. She has found that the cleaners, paid the equivalent of just £40-50 per month by the hospital for full-time work, were keen and willing to improve, taking pride in their work when it was valued and they felt respected. Simple cleaning checklists have been introduced to motivate them and introduce accountability.
In terms of medical care, new educational efforts and protocols have been introduced to sanitise the injection sites and intravenous lines to deliver chemotherapy, and cannula sites are now checked every day for infection.
Hand hygiene is also key. The charity has introduced educational sessions for the medical staff and parents about the importance of hand washing and how lack of hygiene affects children with cancer. Hand sanitizer and soap bars are provided, and doctors and nurses are required to wear gloves. But as with hygiene efforts all over the world, the challenge is getting people to change their behaviour.
The healthcare hygiene conundrum is particularly difficult in the child cancer context. On one hand, the treatment protocols in Bangladesh for paediatric oncology are essentially the same as in the UK or US and relatively inexpensive. The nurse to bed ratio at this cancer ward is reasonable. But the realities of hygiene in a country like Bangladesh work against the best interests of even the most dedicated providers and charity workers: the kids are dirty when they come for care; there is inadequate water supply; facilities to bathe patients are missing; the job of cleaners continue to be undervalued; there is an unreliable supply chain of cleaning supplies; and we worry about sustainability of the charity’s interventions. Parents have to stay with their young ones (many traveling from outside the city), and with no food supplied by the hospital, they store and cook their food on the ward.
And even with the efforts to improve hygiene it’s difficult to know if the interventions are working. There is a strong sense on this ward that infections among the children with cancer are less frequent now that hygiene is being addressed, but a change in infection rates is hard to discern, partly because doctors here so liberally prescribe antibiotics.
Indeed the challenges around healthcare and hygiene will likely worsen and are probably widespread. The number of children with cancer worldwide is expected to increase by 30% by 2020, heightening healthcare needs especially in low- and middle- income countries least equipped. Doctors and nurses will struggle to provide good care: an incredible 38% of facilities in low- and middle-income countries lack access to water and almost a fifth do not have a toilet, according to a new WHO report.
Few would disagree that adequate water, sanitation facilities and hygiene are essential to provide healthcare, prevent infections and limit spread of disease among patients and staff, as well as uphold the dignity of patients. Many would not question that hygiene is essential for child cancer care, and yet more awareness and action are needed to ensure the two go together.