Tag: health

After Ebola: What next for West Africa’s health systems?

A volunteer in protective suit looks on after spraying disinfectant outside a home in Waterloo, 30km outside Freetown. (Pic: AFP)
A volunteer in a protective suit in Waterloo, outside Freetown. (Pic: AFP)

As rates of Ebola infection fall in Guinea, Liberia and Sierra Leone, planning has begun on how to rebuild public health systems and learn lessons from the outbreak.

Nobody is declaring victory yet. But in Sierra Leone, the worst-affected country, there were 117 new confirmed cases reported in the week to 18 January, the latest statistics available, compared with 184 the previous week and 248 the week before that. Guinea halved its cases in the week to 18 January – down to 20 – and Liberia held steady at eight.

The epidemic is not over until there are zero cases over two incubation periods – the equivalent of 42 days. “It’s like being only a little bit pregnant – there’s no such thing as a little Ebola. We have to get to zero, there can be no reservoirs of Ebola,”  Margaret Harris, spokesperson of the World Health Organisation (WHO), told IRIN.

But after 21 724 cases and 8 641 deaths in nine countries since the epidemic began in Guinea last year, there is some light. And health workers are already starting to look at what’s next. “Right now important meetings are going on in each country to work out what needs to be done to rebuild – in some significant respects to build health systems almost anew – and to build back better,” said Harris.

A European Union donor conference is due at the beginning of March in Brussels. “What we want to see as a country is a resilient health system that can withstand shocks,” Liberia’s Assistant Health Minister Tolbert Nyenswah told IRIN. “Our plan [to be presented in Brussels] will be finalised by the end of February. It will be well costed with tangible goals.”

Ebola tested the public health systems in the three West African countries to near destruction – most places in the world would have also struggled. But where the three failed was at the basic “nitty-gritty” level of “standard surveillance, testing and monitoring, the containment of cases, the bread and butter of public health”, said Adia Benton, a social anthropologist at Brown University in Rhode Island.

Citizen and state
A successful malaria campaign in Sierra Leone last week, which reached 2.5 million people, and a planned polio and measles vaccination programme in Liberia, are positive signs for the health services. But the list of necessary reforms is long: stronger surveillance; healthcare that will work after the international partners leave; access to affordable services. The list must also embrace longer-term structural changes, including the relationship between citizen and state.

According to Antonio Vigilante, Deputy Special Representative for the Consolidation of Democractic Governance in the UN Mission in Liberia, and Resident Coordinator, “there is a golden opportunity to have a different start, to have a more balanced development that leaves outcomes in the hands of the people. It’s a very delicate stage, full of opportunities, which should not be missed.”

Liberia is one of the world’s poorest countries and Ebola has been a tragic addition to the burden. It has destroyed livelihoods; already dizzying rates of unemployment have worsened; and food prices have soared. Both rural and urban communities are suffering.

Vigilante is worried the economic impact of Ebola, and the interruption of immunisation and reproductive health services during the crisis, could put more people at risk than the virus itself did. “A number of [social protection] measures in the recovery phase would need to be universal,” he said. One example would be if Liberia scaled up its pilot Social Transfer Programme, launched in 2009, to provide just US$40 per year to two million children. There would be sizeable “knock on effects on local markets and entrepreneurship” at minimal cost, according to the Washington-based Centre for Global Development.

Schools are due to re-open on 2 February in Liberia, and a strong case could be made for a universal school feeding programme to attract and retain children in class. “Even before Ebola many children were out of school,” UNICEF spokesman in Liberia, Rukshan Ratnam, noted.

Money matters
But will the donors come to the party? Donors pledged $1.5 billion to a UN coordinated appeal for Ebola last year, but $500 million is still unpaid. “If we cannot close that funding gap we will snatch defeat from the jaws of victory. It’s as simple as that,” Bruce Aylward, WHO assistant director-general in charge of the Ebola response, told reporters on January 23.

Wasted dollars can be expected in a crisis when the priority is effectiveness – stopping the outbreak – rather than efficiency in how the money is spent. That equation will change if Ebola does not come roaring back with the rains in April, and donors begin to look at competing needs.

There is potential to re-purpose Ebola infrastructure – some of it now idle with a glut in treatment facilities – if donors are willing to be flexible, said Vigilante. Laboratories used for testing could be incorporated into national laboratory services; some of the more permanent treatment units could be re-launched as community-based health facilities; contact tracers could be used as community mobilisers.

“We certainly lost staff as a result of Ebola. But the converse of that is there was a very rapid upskilling as people were trained to work in the treatment units or as contact tracers. It’s a group we should build on,” said Harris. “It’s really important we don’t lose them in the transition to a normal service.”

Local heroes
Among the lessons learned across the region has been the importance of consulting, engaging and empowering local communities: their lack of trust in central government was a major handicap in tackling the epidemic. “Community, community, community. Engagement, engagement, engagement,” said Harris. “We need to listen more. We need to do a lot of work with sociologists and anthropologists.”

Liberia in particular has a highly centralised system of government, but local communities have emerged as critical players in the response with a new can-do attitude. “People given a chance can do a fantastic job,” said Vigilante.

Obinna Anyadike, Editor-at-Large for IRIN

Zambia: Teens turn to text messages for Aids advice

An Zambian HIV counsellor looks at phone text messages coming up on the U-report platform for HIV and Aids awareness at a call centre in Lusaka. (Pic: AFP)
A Zambian HIV counsellor looks at text messages coming up on the U-report platform for HIV and Aids awareness at a call centre in Lusaka. (Pic: AFP)

The questions teenagers ask about HIV are brutally honest, anonymous – and sent in 160 characters or less over mobile phone text messages.

At U-Report, a Zambian HIV advice organisation, thousands of bite-sized questions come through every day.

One asks, “I have a girl who has HIV and now she is talking about marriage what can I do with her?”

Another wants to know “when you kiss someone deeply can it be possible to contract the virus?”

Though Aids-related deaths are significantly decreasing internationally, they continue to rise among adolescents, according to a Unicef report released last week.

But services like U-Report are offering a new way to get through to teens too afraid or too embarrassed to talk to health care workers face-to-face.

Located in a nondescript office building in Lusaka, the counsellors sit behind desktop computers answering SMS queries on everything from how the virus is spread, to the pros and cons of male circumcision.

Launched in 2012, the service now boasts over 70 000 subscribers and is being used as a model for other countries, including South Africa and Tanzania.

“We are receiving messages from all over Zambia,” said manager Christina Mutale. “It went viral.”

Significantly, a third of participants are teens, those most likely to die from Aids.

Sitting in a garden outside the Lusaka clinic where she receives her treatment, U-Report user Chilufya Mwanangumbi said counsellors could be hard to find.

High infection rate
With purple-painted nails and dreams of being a civil engineer, the 19-year-old student is one of Zambia’s many teenagers living with HIV.

“At other clinics, they don’t tell you what to do, they just tell you you’re positive and send you home with the drugs,” said Mwanangumbi.

“That’s when people kill themselves – because they think it’s the end of the world.”

UNAIids, the UN agency battling the disease, estimates 2.1 million adolescents are living with HIV in 2013, 80 percent of them in sub-Saharan Africa.

Zambia has one of the highest HIV infection rates in the world – an estimated 13 percent of its 14 million people are infected.

Signs of the epidemic are everywhere.

In the Saturday Post newspaper nearly half of the classifieds section is filled with adverts for herbal cures for HIV and Aids, alongside remedies for  wide hips and reclaiming lost lovers.

And while U-Report is starting to address the teenage HIV crisis, the barriers to success in the country are high. Even if teens get access to counselling, they may struggle to find a suitable clinic in Zambia, where there is a chronic shortage of doctors and health workers.

Medical services and technology
Yet there has never been a better time for a mobile phoned-based counselling service.

By the end of 2014, there will be more than 635 million mobile subscriptions in sub-Saharan Africa, a number set to grow as phones become cheaper and data more readily available, said Swedish technology company Ericsson in a recent report.

Zambia’s text message experiment is part of an international trend that is seeing medical services being provided via technology, with digitally savvy teens the quickest to adapt.

“The long-term findings on adolescents, health care and computer technologies is that they often prefer them to face-to-face communication,” said Kevin Patrick, director at the Centre for Wireless and Population Health Systems at the University of California, San Diego.

“They will more likely confide in a computer about sensitive issues.”

And as Zambia wrestles to shore up its overwhelmed health care system, inexpensive mobile technology could help ease the strain.

“Apps exist to help people locate the closest HIV testing site,” said David Moore, a professor at the University of California, San Diego, researching mobile technologies and HIV. “What if you could do something like an HIV rapid test using an app on your phone? That could be a game changer in terms of HIV incidence.”

Tackling mycetoma: A medical success story in Sudan

Behind the brick walls of the Mycetoma Research Centre trying to unravel the mysteries of the infection is a rare story of medical success in impoverished Sudan.

With bandages on their swollen, deformed feet, patients from across the vast country arrive at the spotless facility set in a garden in the southern Khartoum district of Soba.

For more than 40 years, British-educated researcher Elsheikh Mahgoub has been searching for answers to the mysteries of mycetoma, a bacterial and fungal infection which can spread throughout the body resulting in gross deformity and even death.

Sudan is particularly affected by mycetoma, which is also endemic in a geographic belt including regional neighbours Chad, Niger, Nigeria, Ethiopia, Somalia, parts of Saudi Arabia and Yemen, experts say.

The belt also stretches to India and parts of Latin America.

Mycetoma is “a badly neglected disease”, the United Nations’ World Health Organisation (WHO) says on its website.

Yet in Sudan, researchers have been studying the condition since British colonial times, and the Khartoum centre has been globally recognised for its work.

Such acknowledgement in the health field is unusual for a country which ranks near the bottom of a UN human development index measuring income, health and education.

Mycetoma is characterised by swelling of the feet but it can eat away bone and spread throughout the body, causing grotesque barnacle-like growths, club-like hands and bulging eyes.

The traditional treatment was amputation – something the Sudanese centre tries to avoid.

Elsheikh Mahgoub, supervisor of Sudan's Mycetoma Research Centre, shows a picture of an infected foot on his computer. (Pic: AFP)
Elsheikh Mahgoub, supervisor of Sudan’s Mycetoma Research Centre, shows a picture of an infected foot on his computer. (Pic: AFP)

“Most patients who get it are farmers, or animal herders, and these are poor people,” says Mahgoub (78).

“They are poor, and they get poorer.”

Mahgoub says he established Sudan’s first mycetoma centre in 1968, working with a British nurse and a British technician.

“Many people thought: Why should I be concerned about this disease which is not common, which is difficult to diagnose, and difficult to treat?” he told reporters on a tour of the facility, which opened at its current location in the 1990s.

The centre offers diagnosis, treatment, training and research as part of Soba University Hospital under the University of Khartoum, which funds it along with some donors.

It has its own laboratory, two wards, and is served by seven part-time doctors as well as Mahgoub, the research supervisor, and its director A.H. Fahal, a professor of surgery.

Though its resources are limited, they have been used effectively, Fahal has written.

Patients come and go – with 6 400 registered so far – but Fahal remains and so does Mahgoub, challenged by the puzzle of why mycetoma is so prevalent in Sudan and neighbouring countries.

“I think there’s two things,” Mahgoub explains, pointing first to the organism’s presence in soil.

He says people who make their living from the land are more likely to get pricked by thorns, for example, from the Acacia trees which are widespread in the mycetoma-prone region and provide a route for infection.

Secondly, the patients have been found with weakened immune systems. Some not only have mycetoma but also Aids, leprosy, tuberculosis or other conditions, Mahgoub says.

“Why? Why these people? Is it nutritional, because of malnutrition? Is it because of the other diseases they get at the same time?”

He does not yet have the answers.

“But we know that they have got some deficiency in their cell-mediated immunity.”

Thorn jab 20 years ago
Mohammed al-Amien Ahmad is a typical case.

The farmer tells Mahgoub that a thorn jabbed him about 20 years ago.

“This thorn came out and it seemed to be OK. Later on the swelling came up. It was a bit itchy,” says the goateed farmer, who is in his 60s and wears a traditional white jalabiya robe.

Ahmad, his enlarged left foot oozing pus, has travelled more than 500 kilometres by bus from Umm Rawaba where he farms about 70 acres of sorghum.

His condition worsened over the past two years, he says, forcing him to reduce the amount of land he can work, and cutting into his annual income of 30 000 – 40 000 Sudanese pounds ($4 300 – $5 700).

In a majority of cases mycetoma is painless, meaning patients like Ahmad delay seeking medical care.

This makes treatment more difficult, Mahgoub says.

“The main thing we tell them is to come early… Because if the swelling is small it can be excised in total,” with follow-up medication, he says.

A patient's infected foot. (Pic: AFP)
A patient’s infected foot. (Pic: AFP)

The Mycetoma Research Centre provides diagnosis and any surgery patients may need for free. But patients may require months of anti-fungal medication, which they must buy themselves.

Some who cannot bear the financial burden stop taking their medicine, Mahgoub says.

“In that case the disease will just go back to where it started. That’s a real problem,” he says.

Drug prices in Sudan have climbed over the past two years as Sudan’s currency plunged in value and inflation soared.

Sudan’s health ministry has expressed concern about the emigration of doctors and other health professionals seeking better salaries and working conditions abroad.

Nationwide, there were 1.3 health workers per 1 000 people in 2011, against the WHO benchmark of 2.3.

Many primary health care facilities in Sudan “lack appropriate medical equipment and supplies, have inadequate infrastructure or are understaffed,” the United Nations said this year.

In contrast, the Mycetoma Research Centre “is recognised globally as a world leader”, an informal group of experts on the disease wrote after their first meeting this year in Geneva.

Ian Timberlake for AFP.

The story of mPharma

It was an early morning in downtown San Francisco a few months ago and I was sitting in a Starbucks, thinking about what next to do with my life. After two successful interviews with Google, I had a good feeling that I would receive a job offer, but something just did not sit right with me. Around 9am, I received an email from a friend which had a link to an investigative article titled “Dirty Medicine” on CNNMoney. It tackled the issue of criminal fraud in Ranbaxy Laboratories, an Indian multinational pharmaceutical company. This article marked my return to Africa and my quest to use big data to help African governments develop better drug surveillance and monitoring systems.

The piece on Ranbaxy outraged me. The author writes that in a conference call with a dozen company executives, one brushed aside fears about the quality of the Aids medicine Ranbaxy was supplying for Africa. “Who cares?” the executive said. “It’s just blacks dying.”

At that moment, all I could think about were the 84 children who died in Nigeria in 2008 after consuming adulterated baby teething mixture and the many other families who have lost a loved one due to substandard/fake drugs. I was frustrated by the silence on the part of drug regulators in Africa. Why were they not dragging executives of Ranbaxy to court? Why was no one in prison for betraying the trust of consumers? Why? Why? Why?

I moved from asking myself why to thinking how. How do we develop technology solutions to address the challenges with pharmacovigilance in Africa? Out of the 46 countries in sub-Saharan Africa, only four have proper drug monitoring systems in place. The reality is that African drug regulators have limited to no means of monitoring medicine use or effective pharmacovigilance capabilities at hospitals. Doctors in turn are unfamiliar with the practice, overburden due to the low doctor to patient ratios and wary of admitting liability. Pharmaceutical companies also lack the incentives to adhere to them. Only 17% of countries in Africa mandate pharmaceutical companies to conduct post-marketing surveillance.

(Pic: Flickr/hitthatswitch)
(Pic: Flickr/hitthatswitch)

We need a better way to collect, store and process data on adverse drug effects. We need to develop a population based approach to drug monitoring. Luckily, the tools to build these solutions are right in front of us. A few decades back, not only would we not have known what data to measure, we also would have lacked the tools to record the data we measured. Today, with Africa leapfrogging the world when it comes to mobile technology, we can turn every individual into a data collector. mPharma is building an integrated drug monitoring system that connects hospitals, patients and pharmacies to a cloud-based software for the easy collection, and analysis of adverse drug reports.

Currently, mPharma is collaborating with the Zambian health ministry and the Food and Drug Authority in Ghana to pilot the system in their respective countries. I am inspired to see other African innovators develop tools to fight counterfeit drugs. My friend Bright Simmons pioneered the concept of serialisation and built mPedigree to enable consumers check the authenticity of their drugs through simple SMS messages.

Since returning to Ghana, I have been inspired and encouraged by the enterprising character of Africa’s millennial generation. Out of the many challenges the continent faces are massive opportunities to build disruptive technologies to solve these problems. Africa will soon see the birth of a massive technology economy. A lot more young people will build tools to solve problems in their communities that could turn into profitable businesses. The West shall look to Africa for answers to their problems and the continent will no longer be, in the words of Juliet Roch, “global consumers of solutions but rather creators”.

Gregory Rockson has worked in the healthcare sector in Africa since he was 16. He founded the Westminster United Way Free Health Fair to provide free health services to the uninsured in Missouri, USA. Connect with him on Twitter.

Rockson is one of 10 young Africans shortlisted to be a One Young World delegate at this year’s summit. At this event, the M&G’s Trevor Ncube will be chairing a session on African media and what Africans think of their journalists. To share your views, complete this short survey.

Have blade, will operate: Kenya’s jigger bugs

I woke up this morning to a strange sensation in my baby toe – a cross between an itch and a sting. On closer inspection, I noticed a transparent, pea-sized blister with a black dot in the middle. Living and working in some of the more dodgy areas of this wonderful continent, I am quite accustomed to insect bites and itches so I didn’t pay it much attention.

A few days later, my husband and close friend observed that they had similar ‘blisters’ on their toes. We had a group inspection in which we all spent a few minutes seated outside studying each other’s toes. Our investigation revealed that a) I still have blue paint on my feet from a project I worked on a few weeks ago; and b) our little blisters were identical: same colour, same size and the same strange sensation.

We called one of the local fishermen who was walking past and showed him our toes.

“Jigga Jigga Jigga!” he exclaimed. “You remove now before she gets more happy in your toe. She is not a good guest for your toe. You need to remove now.”

We decided that we did not want a non-paying guest staying in our feet and tried to find out how to remove them. We did a bit of research: these buggers are parasitic fleas called jiggers. They live in soil and sand and feed intermittently on warm-blooded hosts like cats, sheep and … our feet.

To reproduce, the female flea burrows head-first into the host’s (my/our) skin, leaving the tip of its abdomen visible through a tiny hole. This orifice allows the jigger to breathe and defecate while feeding on blood vessels! In the next two weeks, its abdomen swells with up eggs, which it releases through the hole to the ground to hatch and lie in wait for the next unsuspecting “host”. They need to be removed whole or they will spread.

Is that not the most disgusting thing you have ever heard?

The most fascinating discovery for me was that jiggers are a common and serious development issue in East Africa. A local NGO, Ahadi, is  committed to creating jigger infestation awareness. Established in 2007, it has established 42 help centres in Kenya, and provides services like education, treatment, fumigation of homes and schools, and medication to hundreds of thousands of jigger-infected people. Without treatment, they can lose their ability to walk and work. Kids drop out of school, and stigmatisation and low self-esteem are common effects. There is also the risk of HIV being passed from person to person when needles used to remove these buggers are shared.

The more we read about jiggers the more we wanted to get rid of them, immediately.

In Kenya, there is “a guy” for everything you need. You want fresh octopus, you know “a guy” to call. You want to fix your roof, your toilet, your car, just call “a guy”. I was not surprised that there is a “”jigger guy” too. He was summoned.

He looked like Mr T, complete with the gold chain and signature haircut. He showed us how to remove the bugs. His method involved using a pin and blade to cut a circle around the infected area. He then lifted the skin off, somehow it gave without much hassle. Suddenly, the white egg sack was visible. He carefully dug out and removed the sack without piercing or damaging it. It is bloody sore and left a pea-sized hole in my toe. He made me bite down on a chapatti while he did it. I guess this is a form of Kenyan anaesthesia I had not heard of before.

A health worker at the Good Life Orphanage in Kenya treats a child's jigger-infected toe. (Flickr/The Good Life Orphanage)
A health worker at the Good Life Orphanage in Kenya treats a child’s jigger-infected toe. (Flickr/The Good Life Orphanage)

Mr T had to leave after performing my surgery. He was quiet throughout my mini operation, and as he left he said: “Now you see me do it, now you can do the rest. Just do.”

Just do. With those words, I became the designated jigga removal service provider. I had my two patients bite down on a chapatti and attempted the same procedure on them. Since it was dark I did it with a head light and the torch on my phone. Cut circle, lift skin, remove sack (try not to let the eggs spread all over), clean, cover. Easy breezy.

I am pleased to report that I removed both egg sacks intact. It felt like quite an accomplishment.

This is why I love Kenya and my continent. It is constantly schooling me in lessons I would never receive anywhere else. There are lessons of survival everywhere – even under my toe.

Bash, from South Africa, is a freelance project development analyst based on the south coast of Kenya. She spends most of her time snorkelling, is obsessed with giraffes, has too many tattoos and loves traveling. She misses Nik Naks and Mrs Balls chutney.