Sunday, April 27, 2008

World Malaria Day

This past week has seen World Malaria Day, aimed at focusing the world's resources on irradicating this ancient and terrible disease. On Sunday I caught and article in the Washington Post, 'Eradicating Malaria Worldwide Seen As a Distant Goal at Best'
The article, well written and compelling, stirred me to write down my thoughts on the subject.

I live in a place that has the highest number of infected mosquitoes in the world, a District in northern Uganda. That's what the Ministry of Health and WHO tell me. It also has the third highest fertility rate, 1.2m babies born each year. Average age of population 14.9yrs. Put the two together and you get a huge infection rate that without radical action will continue to grow with the population explosion. Most deaths from malaria are babies, kids under five and pregnant women. It is not just deaths either, my town has a huge number of disabled children, their brains damaged by being boiled by malaria fevers or by being directly infected by the parasite

There is no silver bullet solution. My current work, a baseline study on malaria/HIV/TB gives me a close up view of the reality of malaria. The people tell me they cannot live 24/7 under an ITN, they often get bitten in the evening, eating supper or doing homework. They tell me too I should try sleeping under a net in a 12' hut crammed full of people on a red hot airless night. I can imagine. I have a big net in a 12' bedroom and a fan on all night. When the electricity fails (often) I sweat buckets and find it hard to sleep. I understand why, despite the risks, the people don't use them every night.

Moreover, most people here view malaria the way people in the US or Europe view a bad cold, and sometimes thats how it affects fit, healthy adults with partial immunity. So data on the disease is hugely inaccurate. There are already reports of ACT resistance, though no confirmed data. . I am not surprised, ACT like other antimalarials, is frequently used without firm clinical diagnosis. If the symptoms disappear after ACT treatment, it must have been malaria. ACT is costly; the stuff, now given free by MOH, it is often stolen, repacked and ends up for sale in village shops and even in neighboring countries. Health centers in my District, which have no ACT, direct patients to buy from the 'chemist shops', often supplied by the same healthcare workers. Selling medicines is often justified as the only means of subsidizing very poor salaries.

The nation's healthcare system is overwhelmed by population pressure and the burden of disease and under-mined by shameless corruption. The brain drain of healthcare workers, migrating to the US, Europe and other developed countries, to escape the appalling conditions of work and pitiful salaries, is accelerating the dissolution of the national health service.
There is no history of any nation with a ruined healthcare system ever successfully conquering any infectious disease, least of all one as old and complex as malaria

IRS, using DDT, the cheapest, most effective agent, has just begun here. It remains to be seen whether the expansion of the malaria campaign into a coherent, focused effort to include IRS, ITNs, ACT and education will have lasting impact on the disease, but I am pessimistic, without a vaccine.

As expected the campaign to use IRS is being dogged by the pious ranting of the self-appointed guardians of Africa's ecosystem, as if Africans were too stupid to understand the arguments and reach their own decisions. I have little time for such organizations as Beyond Pesticides. One would do well to remember that its staff earn a comfortable living through this NGO, lobbying on behalf of poor Africans. They have very comfortable offices, alongside the the lobbyists of E Street in DC. Their office rent would buy a huge number of ITNs.

They know the scientific evidence they quote is based upon massive use of DDT as a pesticide in US agriculture in the 1960s, when planes were used to dump tons of DDT per acre on cotton fields and fruit orchards. Even with this massive industrial overuse, the evidence, after 50 years of scientific scrutiny, connecting DDT with diseases in humans is thin indeed. IRS will use less DDT in a year across the entire country, than was dumped on a few acres of US cotton in the 60s

My advice to anyone who wants a credible voice at the table, is to come and live here, out in the countryside, away from the Cities, for a couple of years. To live without expensive Malarone prophylactics and designer insect repellants and about 200 miles from the nearest capable hospital

They are welcome to come with me to the villages to convince people they need to use an ITN all the time. They could also try and explain their version of the facts regarding IRS and DDT; tell mothers that "DDT can be passed on in breast milk". For many it will be an irrelevance, they will not be feeding their dead babies.
4/27/2008 7:15:09 AM

Saturday, April 26, 2008

The Global Health Workforce Crisis

‘Over several decades, a global health-workforce crisis has developed before our eyes. The crisis is characterized by widespread global shortages, maldistribution of personnel within and between countries, migration of local health workers,
and poor working conditions.’
- World Health Organization. World health report 2006

There Were Reports
In late February I was surprised to find our home-town, Lira in northern Uganda, in the international news. And it wasn’t a 60 word paragraph by Reuters. Lira made it all the way to the hallowed ground of the Lancet Editorial; fame indeed! Actually one might better describe it as infamy.
Now I for one know the temptation of purple prose, but I expected more of the Lancet. Given our remoteness from London, or for that matter, anywhere on Earth, I can only surmise the Editor got his information from the Ugandan ‘Dailies’, which delight in hyperbole. The result was an opening paragraph that read:

“Earlier this month, medical workers at Lira Hospital in northern Uganda went on strike to demand unpaid allowances promised by the government for working in this war-torn area. Seven patients died. There were reports of bodies decomposing in wards and women in the maternity ward assisting with each other’s deliveries. “

Let’s set the record straight. I was there when it happened. The lady that keeps our house went into labor; I took her to the hospital, witnessed the chaos and took her to a private clinic. I wrote a blog about it called ‘Super Tuesday’. I followed events very closely for the next few days.

The healthcare workers went on strike because they had exhausted every other option. They had been promised the money for almost a year, every other healthcare worker in the Region had received an ‘allowance’ and they had been stone-walled. This is not uncommon. Teachers commonly go for months without being paid their tiny salaries of about $100 a month. It usually happens because some bureaucrat has ‘eaten the money’, a local euphemism for stolen it.

The brave but na├»ve District Medical Officer of Health, was publicly derided when he suggested that the ‘seven patients who died’ would have died with or without healthcare workers present. Knowing the resources available to the hospital, I do not doubt him. ‘Women assisting each other with their deliveries’ is another hyperbole. Most Ugandan women come to deliver in hospital with droves of mothers, aunts and sisters; some with their own village birth attendant. That’s how the deliveries were done. As for, ‘bodies decomposing in wards’; this a hot place, there are no undertakers. Funerals take place pretty quickly.

Global Forum
The irony of this strike is that it took place a few weeks before the first WHO Global Forum on Human Resources for Health, hosted in Kampala. That, I suppose is why Lira made the Editorial, coincidence. I did not attend the Forum; no report has yet been published. I have however, received anecdotes aplenty. Given the scale and political complexity of the [healthcare workforce] crisis, it is not surprising that the meeting produced a lot of heat but little light.

What happened in Lira was a reflection of events played out every day across Africa, which has 25% of the world’s disease burden and only 3% of the world’s health workers. The reasons as to why this imbalance exists are manifold, but the political heat centers around one argument, the migration of healthcare workers, trained in Africa, at African expense. The accusation is they are lured away by unscrupulous recruiters with promises of huge salaries, to meet the ever-rising demands of caring for the aging population of the developed world, leaving their own countries bereft and in crisis.

In the eyes of many, this is yet another example of predatory exploitation of African resources by the developed world. In condemnation, the Lancet editorial ends with a pious flourish, “[R]icher countries can no longer be allowed to exploit and plunder the future of-resource poor nations” . Such sanctimony suggests migrating doctors and nurses are victims of a modern slave trade. Nothing could be further from the truth. Many leave because it is in their nature to explore and seek advancement; but for the majority it is because working in healthcare at home is under-paid and overwhelming. Moreover, despite the promises of the international community and the proclamations of African governments, in most countries, there are no signs of things improving, rather they are getting worse.

Responsibility for the distortion in the healthcare workforce can as easily be laid at the feet of the huge numbers of Non Government Organizations and International Agencies as it can ‘malign foreign recruiting agencies’. It is they (INGOs) who recruit the cream of the public sector, offering in-country salaries and employment opportunities that cannot be matched by governments. It is the dream of many of my medical friends to get permanent employment with ‘a big international NGO’ or better still the ‘Holy Grail” of international healthcare employment, the WHO.

The extent of this distortion is evinced by the number of surgeons and surgical staff in Africa. Uganda for example, has about 75 general surgeons and ten physician anesthetists for a population of 30 million people. Most live and work in Kampala. The majority of surgery is performed in rural hospitals by the equivalent of family physicians. Why this dearth of surgical capability? In part because the public sector pays poorly, private surgery is limited and few INGOs are into surgery, so rarely hire surgeons. Better by far to enter a career in public health and specialize in HIV, TB and Malaria, that’s where the [NGO] money is. To emphasize the point, Makerere University recently restricted entry into its Masters in Public Health program to physicians.

The reasons for Africa’s healthcare worker crisis are too many and complex for reasoned debate in this essay. They will no doubt be the subject of many future PhD theses. I will offer a few comments about two factors, using Uganda as an example; few countries on the continent are markedly different.

The first is that of population pressure. Uganda is undergoing a population explosion. The national Total Fertility Rate - about 7 - is the third highest in the world. As a result, despite the ravages of war, disease and staggeringly high maternal and infant mortality rates, the population has leapt from 6m in 1962 to about 27m in 2007. Moreover, average life expectancy has dropped, mainly due to HIV/AIDS, producing a skewed population with a mean average of 14.9 years. Barring some apocalyptic event, Uganda’s population will reach 60m by 2025. Economic growth is nowhere near keeping up with this massive and rapid population increase; every aspect of national infrastructure is overburdened. Electrical power is rationed, schools are overwhelmed with pupils and have pitiful resources, roads are falling to pieces as fast as they are built and emergency services non-existent in most of the country. Uganda has for example, ten fire trucks; four are in Kampala. Nowhere is this overburdening more obvious than in healthcare.

I offer a few anecdotes in illustration; first in the arena of mother and child care. I am currently working on a project in Luwero District, central Uganda. Recently I visited the largest healthcare unit in the District, called a Level Four health center; there is no Referral Hospital, though there are about a million people in the District. The unit is small, old and in disrepair. The maternity unit has ten beds and one delivery room with one table. When I looked in, there were 15 women who had delivered in the past 12 hours, five were on the floor. The overworked but dedicated midwife told me they averaged 450 deliveries a month. She added that other smaller District health centers were similarly overstretched. This is in an area where about 60% of women deliver at home.

My next-door neighbor is the only surgeon in Lira hospital. He was away during the strike, but some weeks before he had experienced an incident that exemplified the sheer weight of his work and the paucity of resources. Late one evening a truck loaded with worshippers returning from a ‘Revival’, overturned about ten miles from town. The town has no emergency services; the casualties arrived in traditional fashion, in the back of private vehicles, usually pickup trucks co-opted by the police as ‘Good Samaritans’. By the end of the night he had 90 casualties; seven had died instantly or en route. His only assistants were a family doctor doing Ob/Gyn, an Anesthetics Officer and a handful of nurses. Help, in the form of one doctor arrived the following day. It took him three days and nights to complete the surgical care for his 90 patients.

A few weeks ago, in a town not far from here, a furor erupted over the town mortuary. Plans to refurbish the unit had run out of money. However, the doors at least were fixed. This, according to the town council was major improvement. Prior to that, dogs had chewed of parts of bodies and local ‘thugs’ had used the place to skin stolen goats and cows that would end up in public butchers. The council stated that hygiene remained a problem however. “The mortuary has neither a refrigerator nor is connected to electricity and given there are no drugs for preservation of bodies, some end up rotting”.

As I was preparing to write this article I glanced at a short byline in a national daily. I offer it verbatim. “Close to 200 health centres across the country can no longer offer immunisation services after they ran out of gas for the refrigerators in which the vaccines are preserved. In a] survey done in 22 districts by a concerned party within the Ministry of Health, out of 534 health centers sampled, 198 had stopped offering the services by the beginning of March. There has been no delivery of gas to the centres since January
15. Vaccine shortage poses grave risks to pregnant mothers and their babies who risk missing the tetanus immunity at the time of delivery. Uganda has at least 1.2 million children born every year countrywide”.

Corrupt and Inept
The second issue is that of Corruption and Ineptitude, so inextricably linked I consider them as one. Corruption has permeated every facet of public healthcare in Uganda, from the very top to the remotest health center. The reasons range from shameless greed at the top to survival at the bottom. But at root the problem is OPM (Other Peoples Money, a euphemism for foreign aid). Ugandan healthcare attracts huge amounts, too much for an inept bureaucracy to manage. The temptation to ‘eat it’ or miss-use it are huge, the results glaringly obvious. Headquarters MOH in Kampala has so many SUVs in its parking lots it has earned the sobriquet ‘Ministry of Land Cruisers’. Few of these vehicles ever leave Kampala city limits.

The previous Minister of Health and his immediate staff, currently face charges of misappropriating millions of dollars of Global Fund monies. Funds meant to buy and distribute anti-retroviral drugs, drugs for TB and antimalarials. A glance at the inquiry findings shows it was done with breath-taking impunity. My favorite anecdote concerned evidence given to the initial inquiry. The judge was shown a receipt for fuel for an MOH vehicle traveling thousands of kilometers around the country on “HIV sensitization duties”. The vehicle registration on the receipt belonged to a Caterpillar tractor. My friends were not amused; they called it ‘stealing from the dying’.

The upper-mid level of the Ministry has followed their leader’s example and the new Minister is not strong enough to break their stranglehold. The National Medical Stores (NMS) an autonomous governmental organization is so riddled with theft and ineptitude it has become a national scandal. The current Minister has publicly stated he wants the boss sacked, as yet to no avail. The NMS is the only means of supply and distribution of medicines and medical equipment to the public healthcare system. Its reputation for incompetence is all-pervading. The project I am currently working on has a caveat in the proposal regarding the availability of medicines and medical materials for HIV/AIDS, TB and Malaria, one line reads, “[N]MS itself has systemic problems that lead to stocks out”. That is a huge understatement.

Lira District health centers currently have no AARVs and have not had for months. Neither do they have the new antimalarial, Artemesin Combined Therapy (ACT) but I know at least four ‘chemist shops’ in town where I can buy them and just about anything else. Where and how they got them, the traders will not say. The same would probably be true in most of the country.
At the bottom of the food chain, a District Medical Officer of Health has just been charged with stealing a refrigerator and gas bottle from one of his health centers. It was found in his quarters, filled with beer. There is no word of the vaccines.

Ineptitude is not the sole prerogative of the MOH. Some of its INGO partners appear to have either given up their Sisyphean task or in some cases let the rock roll downhill. You will remember the anecdote about the maternity wing in Luwero. Directly across compound from this building there stands a brand new construction, built by one of the most renowned INGOs. Locked and never opened, it was built as a ‘center for acutely-malnourished children’. A laudable purpose, but acutely-malnourished children seem to be in short supply locally. The building would make a great new maternity unit.

About 10 miles out of town, down a very long muddy track, with a few small villages, there is a brand-new maternity unit, built by the same INGO. It dwarfs the Level Three healthcare center it serves, has about 50 beds and all the equipment required outside of emergency surgery. The problem is nobody uses it. Well; about 5 women a month have given birth in it since it opened, which is probably a good thing because it does not have one toilet, bath or shower. The midwives have dug a latrine outside. I just cannot figure out how it came to be built there, but there is a huge new house a little further down the track.

In conclusion, I admit to only touching the margins of the crisis Africa faces in healthcare and its healthcare workers but I hope I have provided some light and thought for debate. I will add one more comment. I consider the idea that doctors, nurses and other health workers born and trained in Africa should be prevented from working abroad to be abject sanctimonious nonsense. Why stop at healthcare workers? Why not ICT workers? University professors?

We should ask young doctors and nurses why they leave this beautiful, tropical country, their families and cultures, for the cold rain of Manchester, England or the frigid plains of North Dakota.
When we have listened to the answer, we will be some way to fixing the problem.