Protecting the Living while Honoring and Dignifying the Dead By Dr Mary Amuyunzu-Nyamongo
Since the emergency of COVID-19, Kenyans have been confronted with a lot of guidance from the Government on how to limit exposure to the virus. Kenyans have attempted to adhere to these guidelines but a simmering conflict related to the way we honour and bury the dead seems to have followed the recommendations issued to guide the way people mourn and bury their loved ones.
There is a conflict of culture versus safety. Cultural and communal considerations on the one hand and the changed times occasioned by the pandemic. The discourse now is how can we honour and dignify the dead and still observe safety?
There have also been elaborate directives issued on burials like the body must be buried by the family as soon as possible (within 48 hours) and under the supervision of healthcare personnel, the local healthcare committee leader and religious leader; once the body has been delivered to the mortuary (if the person died at home), the casket must be cleaned and disinfected using the standard procedures; the body should not be reopened for viewing once it is put into the casket; and the family members should ensure they coordinate transportation of the body with the local health officials, among other things.
The World Health Organization (WHO) guidelines put emphasis on family involvement but this has not been the case in some instances in the country. In some cases, family members have not been allowed to participate in the burial arrangements which has led to disquiet and, in recent times, revolt by communities. The burial process is often rushed with security forces ensuring completion of the ceremony in the shortest time possible. In one case in Bomet, the widow lamented that she, and her children, were not allowed to be part of the ceremony.
In many African communities, the concepts of "life" and "death" are not mutually exclusive, and there are no clear dividing lines between them. When the Siaya man was buried in the middle of the night (in May 2020), there was an outcry of ‘you cannot throw our son away like a dog’ that resonated across the country.
In the past two days, there has been a clip doing rounds on social media of a community in Migori that chased the public health officers, opened the casket and body bags and properly mourned their son before he was buried. There was also a story of a Luhya man whose body was exhumed to allow the community to give him a proper burial. The elders indicated that the body needed to face the right direction and they had to remove the shoes, tie, belt, etc. because he was not supposed to have been buried in these items. The elders noted that unless they re-buried the body, the dead would come back to haunt his family.
It is notable that death does not alter or end the life or the personality of an individual, it only causes a change in its conditions. This is expressed in the concept of ancestors, people who have died but who continue to live in the community and communicate with their families. Hence, the manner in which burials are conducted continues to be a contentious issue in the country. I have participated in several conversations on COVID-19 stigma and several people have asked ‘if a corpse is infectious.’
In one such discussion Dr. Johanssen Oduor, the Government Pathologist, clarified that although the body is normally sanitized and double bagged, what the government directives intend to do is to limit crowding around the body and touching the casket which could lead to the spread of the virus if any of the mourners is infected. The scenario in Migori, where mourners touched the deceased after opening the body bags and surrounded the casket, was such that if any of them was infected, the exposure to the others would have been high due to free mingling and exchange of fluids, including tears.
Mourn for the Dead while Celebrating Life
It is notable that burial ceremonies allow communities to mourn for the dead while celebrating life in all aspects. Funerals provide opportunities for communities to be in solidarity and regain identity. In some communities this may include dancing and merriment for all but the immediate family, thus limiting or even denying the destructive powers of death and providing the deceased with "light feet" for the journey to the other world (see Allan Anderson). Last month, I asked my mum not to attend a burial in the community and she informed me in very clear terms: “this woman has stood with me over the years. She was here when I lost my daughters. She cannot be buried while I am at home. I will remember to carry my mask (this may have been added to appease me)”.
Although churches have tried to eliminate the old practice of sending off the dead to the ancestral world, they have done so without neglecting the traditional conception of ensuring harmony with the ancestors. However, since a funeral is usually a community affair in which the church is but one of many players, the church does not always determine the form of the event. Some of the indigenous rites have indeed been transformed and given Christian meanings, to which both Christians and those with traditional orientation can relate.
There is fear that if the correct funeral rites are not observed, the deceased may come back to haunt the living. There are however exceptions including wizards, murderers, thieves, those who have broken community codes or taboos, or those who have had an unnatural death (e.g. committed suicide). The burials of such people are not celebrated and in many communities they are either buried at night and/or rituals performed to ensure that they do not leave any of their bad omen behind. Hence the question: why did they bury him at night like a thief!
Funeral celebrations are meant to comfort, encourage, and heal the bereaved. Thereafter, the communities and churches see to it that the bereaved make the transition back to normal life as smoothly and as quickly as possible. This transition during the mourning period is sometimes accompanied by cleansing rituals by which the bereaved are assured of their acceptance and protection by God. The requirements for quick burials and no celebrations are leaving many families at a crossroad, with many unresolved questions and mental anguish.
How can we honour and dignify the dead?
In view of these cultural and communal considerations and the changed times occasioned by the pandemic, how can we honour and dignify the dead and still observe safety?
It is important to ensure deeper engagement and involvement of communities in behavior change – communities are adaptable but they can only do this from a point of information and understanding.
Utilize faith-based alliances for building community trust – people trust their religious leaders and they should be central to planning, interment and follow-up of the bereaved families post-burial.
Include both Christian/Muslim and cultural rites in the processes – this is key since for most communities there is a blend between Christian/Islam and cultural rites that should be understood and respected.
Ensure effective capacity building of health personnel, such as burial workers. Training is critical not only for their personal protection but also for the safety of communities. Include women and youth in burial teams.
Protect burial teams including public health officials. The recent incidents of public health officers being chased away from burial homes is a risk to them and their loved ones.
The Non-Communicable Diseases Quality Management (NCDQM) Project aimed at strengthening the healthcare system through improved capacity in management of selected NCDs within four sub-counties of Nairobi County. The settlements included Ruaraka, Westlands, Embaksi East and Embakasi West. During implementation of the NCDQM project, the African Institute for Health and Development (AIHD) worked closely with the Nairobi City County Health Department-NCD Unit, the German Federal Ministry for Economic Cooperation and Development (BMZ), Malteser International (MI) and IntelliSOFT Consulting.
The project used innovative technology to build the capacity of healthcare workers to adhere to clinical guidelines in the management of hypertension and Diabetes Mellitus (DM). Implementing partners developed and facilitated the adoption and domestication of Electronic medical records (EMRs) system in health facilities within the four implementing sites. Notably, the system provided a platform to easily digitize medical data leading to improved NCD health information in 45 selected health facilities. The AIHD team conducted data quality assessment (DQA) to collect data on the two NCDs and assess the quality of data collected in the health facilities.
Apart from the system, the AIHD equipped the health facilities with equipment, lab reagents and other lab consumables. Moreover, healthcare workers and community health volunteers (CHVs) were sensitized on the NCDs, particularly, hypertension and Diabetes Mellitus (DM) both in the health facilities and at the community level.
Non-Communicable Diseases Nairobi County CIP launch
As part of their 2019 Community Ambassador Programme, CIGNA- a global health services company, dedicated to helping people improve their health, well-being and peace of mind. CIGNA partnered with the African Institute for Health and Development (AIHD)-which is a Non-Governmental Organization (NGO) based in Nairobi- to undertake an initiative dubbed “Be Beautiful, Be Healthy”. The aim of this initiative was to mobilize barbershops and salons in Nairobi, to aid in the delivery of health promotion and disease prevention messages on Non-Communicable Diseases specifically, hypertension and diabetes.
Non-communicable diseases (NCDs) represent a major public health problem. These diseases, mainly cardiovascular diseases, diabetes, cancers and chronic respiratory diseases contribute to the majority of causes of death and constitute a major burden for socio-economic development especially in developing countries. The NCDs are chronic in nature and may have no cure; however, existing evidence indicates that these diseases are largely preventable by means of effective interventions. In addition, early detection and proper management of such diseases can reduce morbidity and premature death and may improve quality of life.
The key objectives of the Be Beautiful, Be Healthy initiative were:
The Initiative was launched during a breakfast meeting on July 26,2019 at IBIS Style Hotel, Westlands. Key stakeholders present were drawn from the Government, civil society organization (CSOs), private sector, barbershops and saloons. The aim of the launch was to create awareness and buy-in among the stakeholders.
The target areas for the Initiative were; Kilimani, Westlands, Nairobi Central Business District (CBD), Kenyatta Market, Kariobangi Northand Umoja Market. Ten (10) clinical volunteers (nurses and nutritionists) were recruited, trained and dispatched to salons to conduct health talks on a daily basis. During implementation of this initiative, the AIHD and CIGNA partnered with The Aga khan University hospital and the Good life Pharmacies to offer onsite free medical checkups on Saturdays at the various Salons and barbershops.
The two organizations also partnered with the Nairobi County Health department – NCD unit to ensure sustainability and scale up of the Initiative. Additionally, the Unit acted as the point of referral to the patients who were found to have abnormal readings during the screening process, hypertension cases and diabetics, for treatment.
PATH Kenya contracted the African Institute for Health and Development (AIHD) to implement the advocacy and mobilisation component of the project, Integrated Mother and Baby Friendly Initiative Plus (MBFI+) targeting vulnerable neonates in Kenya. The overarching goal of the project was to contribute to a reduction in maternal and newborn mortality. In Kenya, the project focused on establishing a Human Milk Bank (HMB) in Pumwani Maternity Hospital (PMH).
The advocacy and mobilisation component was based in Pumwani health facility and the community around it. The component focused on promoting uptake of HMB by healthcare workers in Pumwani maternity Hospital and community health volunteers (CHVs) and the community in Kamukunji sub county.
The advocacy and mobilizing component is aimed at creating awareness on the significance of HMB and mobilizing potential donors in Pumwani area to voluntarily donate breast milk to the HMB at Pumwani Maternity Hospital, Nairobi. The specific objectives of the component included:
The advocacy and mobilisation engagements were guided by the following themes: