Tuesday, September 23, 2008

My Magnificent Octopus

“ Black Adder: “What have you got there Baldrick?” Baldrick, “I have written a story. My Magnificent Octopus.” Blackadder: “I think you mean Magnum Opus”.

Baseline Study

We are in our last month in Uganda and will shortly be returning to the US. The end of an era, we will have done six years in East Africa. It has been an experience I would not have missed for the world. I have been back at school for all this time.

My final task has been to undertake a Baseline Study on Malaria, AIDS and TB grouped under the latest aid acronym (MAT) in Luwero and Kiboga Districts, in Central Uganda, for a major NGO. In many ways the results summarize what I have discovered about health and healthcare in this part of the world over the past years and I think it might be worthwhile sharing them.

Just to give some context, the two districts are archetypal Uganda, rural, heavily agricultural, poor infrastructure and communications and little disposable income. There are almost three-quarters of a million people living in the area. The burden of disease, particularly malaria, HIV/AIDS and TB is very high, malaria overwhelms the healthcare system the whole year round.

The Study was designed in three parts: first a detailed survey of every health facility in both Districts, from hospital down to Health Facility Level II - the clinics that serve Parishes, which contain a number of villages - about 75 health facilities in all. Second, a household Knowledge, Attitude and Practice (KAP) sampling survey covering about 100 households in each District, rural and urban, total population over 200 households comprising about 1500 people. Third, a detailed examination of the information systems.

It was great fun and hugely educational. I visited and talked with healthcare workers and the people they serve, many miles from the nearest town or paved road. I saw up close the results of the millions of dollars of aid that the USA and other countries pour into development in Uganda and other African countries annually

A Perfect Storm

In summary, the study identified a ‘perfect storm’ resulting from the concatenation of number of events: a rapidly increasing population ( the Total Fertility Rate is 6.9) with a concurrent huge increase in the incidence of infectious disease, particularly malaria; rising expectations amongst the population, resulting from increased awareness and education; Uganda’s healthcare workforce crisis, there are severe shortages of trained healthcare workers at every level; de-centralization of healthcare, which has spread healthcare resources even more thinly, and chronic under-resourcing and neglect of the national healthcare system. The result is two Districts whose healthcare systems are in crisis. My experience suggests that they are indicative of the rest of the country.

In order to give my story a little more life than a turgid Study Report, I have decided to use the format of a [very lengthy] email I wrote to a long-suffering friend, describing my findings and thoughts on the issues. It may not follow the rules of grammar but I hope it makes the subject less dense


Everyone [we interviewed] knows what causes it and where ‘mozzies’ live and breed. Everyone knows who is at greatest danger, moms and babies. Everyone knows how best to protect themselves and families, Insecticide Treated Nets (ITNs)
Yet less than 40% of the population has an ITN in their houses, very few have two. If you read the newspapers and the advertising of the UN and big NGOs, you would imagine the entire country draped in the ‘things’. Despite the imploring of Bob Geldorf and the rest, the promise of ‘nets for all’ is a myth, we found one facility with a dozen
nets available for hand out in over 75 facilities we surveyed. Almost all [ITNs] are bought and at large cost to families with little disposable income.

Healthcare workers complain constantly about advising moms at ante-natal clinics (ANC) to use a net and yet don't have any to hand out. It is really bad for morale.
Uganda needs to flood the market with free nets to the point where they have no retail value, and there are enough spare to decorate wedding venues and to use for fishing nets, both common practices here

About 60% of all patients visiting health facilities at every level, are diagnosed with malaria. 97% are diagnosed symptomatically. About 60% are diagnosed by nursing or health assistants, with very little training or experience. About 30% are diagnosed by volunteer Village Health Team (VHT) or Community Medicine Distributors (CMDs)
workers, with a couple of weeks training on an array of diseases. About 90% of suspected malaria patients are treated with Artemisinin Combination Therapy (ACT). The drug is handed out by formal health workers and volunteers, like M&Ms.

ACT has rapidly become the most sought- after drug in the Ministry of Health (MOH)
inventory. MOH offer it free of charge. It has become a source of alternative income for many healthcare workers who either sell it to their patients or to businessmen who shift it to DRC and Sudan. The result is an erratic and unreliable supply of ACT. Patients worried about availability, take the drug for 2 of the 3 days prescribed
and then horde the rest, for the next attack on them or their children. It does not take a PhD to know what constant and widespread subclinical exposure of any drug does to its efficacy I think we are on a fast track to ACT resistance, which I believe will be quicker and more terrible than the Chloroquine/Fansidar debacle

60% welcomed Internal Residual Spraying with DDT, 20% opposed the
idea, 20% didn't care. IRS has started in the North, Apac and Oyam Districts, with very good results It has now been stopped thanks to a court injunction lead by British American Tobacco (BAT(U)) and Dunavant Cotton Int. They worry that DDT will leach from the homes and contaminate their crops. The idea of organic tobacco beggars my imagination and vocabulary.

The strategy of providing intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (SP) to pregnant women, though great in theory ( it offers considerable protection to pregnant mums when they are their most vulnerable) is hugely flawed. Most women only come to a health center once during pregnancy,
so they only get IPT1, they need the second dose, IPT2, for better protection, few get the latter. Only 30% of Ugandan women deliver in a health facility.

My general comment about Uganda's Roll Back Malaria plan is it might more aptly be named Operation Sisyphus.


Everyone knows how it [HIV] is spread, 'sex and needles'. Everyone knows how to prevent infection, condoms, faithfulness and abstinence, in that order of import
Knowledge appears to impact little upon behavior. Condoms are available free, even in the most remote locations. Few men use them consistently. Fertility rates in both Districts are estimated at 7. Multiple sexual partnerships, particularly males fathering children with more than one woman, are commonplace.

Prevention of Mother To Child Transmission (PMTCT) is less well known about and the practice very poorly organized. Only 10% of interviewees knew the details. Again, the problem is that PMTCT relies upon regular ANC attendance and subsequent delivery in a health facility. I cannot see the current 30/70% balance changing in the near future. The healthcare system could not cope

Everyone knows about Anti Retro-Virals (ARVs). Everyone knows about HIV testing. Many women test, usually at ANC but often too at outreach clinics now known as HIV Testing and Counseling (HCT): note the change from ‘Voluntary’. Few men test. It seems they don't want to face the truth. HIV testing remains difficult to find in rural areas. HIV testing is scary for all and still carries much stigma. There is a distinct lack of national leadership in testing. The Tanzanian model, the President and First Lady testing in public, is one that. should be copied here. My conversation with the local Anglican bishop, that he might lead a local public HIV testing ‘fair’, fell on stony ground.

ARVs are limited in distribution and erratic in supply. The nearest supply point for a rural villager is Health Center III, at the sub-county level a two day round-trip for many people. Long gaps in ARV treatment are commonplace. HIV treatment in general, is threatened by inept and corrupt national management of medicines and medical equipment by the National Medical Stores (NMS). The term 'Stocks Out' ( medicines have run out) has been incorporated into the national languages. The number of new cases of HIV is increasing faster than the number being put on ARVs
Current methods of prevention appear to be having little impact. There is a dearth of new ideas in prevention

Tuberculosis (TB)

Pulmonary TB is reaching epidemic proportions in both districts. An alarmingly small number know how TB is spread. If you don't know how a disease is spread how can you protect yourself? Few make the connection between HIV and TB. Many TB patients are HIV +. The data is too erratic and poor to give an accurate picture of the % of TB/HIV. Almost 50% of TB patients we found in our survey remained positive at the end of treatment with first-line drugs and had to begin second-line treatment. Directly Observed Treatment Strategy (DOTS) therapy is taken seriously but is undermined by the erratic supply of drugs from MOH. I have had a cough since half-way through the survey

Health Facilities and Staff

Morale in the healthcare system is at an all-time low. MOH is viewed as incompetent and corrupt, by staff and patients. Government is viewed as uncaring and mean-minded with regard to funding healthcare. Salaries and conditions of service for all healthcare workers are so poor as to encourage corruption and neglect.
Kiboga District hospital can fill only 28 out of 88 established nursing posts. Most Level II facilities have about 25% of staff, about two healthcare workers. The quality and experience of staff is as much a concern as the numbers. Many posts are filled by individuals who lack the required qualifications, training and experience. The result is a high level of [symptomatic] diagnosis and treatment, well above the level of staff competency. Less than twenty of the sixty five healthcare units surveyed have working laboratories, it is little wonder that symptomatic diagnosis is the norm.

Housing and accommodation for staff is as big a problem as pay, it stymies recruiting and undermines morale. Continuing professional education is jealously guarded as the prerogative of the most senior staff. Many healthcare workers run private clinics and shops selling medicines, resourcing them with misappropriated medical supplies.
Without this option they would merely subsist.

Very few facilities have any form of power supply and most close at night Few have running water, the staff carry it in jerry cans from the nearest well. Disposal of medical waste is totally ad hoc and quite frankly dangerous. The only hospital in Kiboga hospital has not had running water in 21/2years and has no incinerator either. The daily bonfires are nauseatingly smelly.

The NMS has a contract with a private company to remove out of date medicines. it has never visited the hospital. Out of date medicines are stacked outside next to the hospital kitchen. There is not one functioning ambulance in the entire Kiboga District.
The total annual drug budget for Kiboga is UGSH 200m. Given a population of 280,000, this allows UGSH 770 (50c) ppa.

Some Suggestions

Given the extent of the problems I have detailed in the report, it would be of little value for me to leave it all hanging in the air. As a soldier, I was taught to argue to a decision rather. than simply a conclusion. So I have a few suggestions to offer.

I think we should enhance malaria diagnosis at HC II level through a Malaria Rapid Test and increase community-based oversight of malaria treatment with ACT through a DOTS approach. I think we could increase IPT2 provision by delivery through CMDs and VHTs and increase the availability of ITNS by the same method. There is an urgent need to initiate regional Preventive Education programs for PMTCT and also for TB. There is a vital and urgent need to refurbish clinical laboratories if we are to have any hope of improving diagnosis and treatment.

Finally, and again to quote Baldrick, “I have a cunning plan” to increase the number of men who test for HIV. It involves Corporate Social Responsibility and the 2010 Football World Cup. I will resist the temptation to elaborate further and save the details for my future essay

The Culture of Co-Dependence

Well! That is my "Magnificent Octopus" . Six years in Africa has convinced me the only way we will break the 'Culture of Co-dependence' we call Aid but should properly call Charity, is to find some new ideas. We must centre our thinking around business development and job creation. The dignity of a job is vital for the future stability of Africa's ever-growing and youthful population.

I frequently upset my fellow travelers with what I offer as new ideas, and they consider to be unfair sniping at the Aid Industry. I am currently proposing a six-month moratorium on workshops and conferences. I am informed it would do untold damage to the hotel and catering industries as well as Coca Cola and numerous
Chinese tee shirt and baseball cap manufacturers.

I have also developed an irrational antipathy to certain aid industry jargon; its use has the same effect on me as dragging fingernails down a blackboard. To name a few: sensitization, holistic, gender-based, participatory and most irritating of all ….. youth-friendly! A more patronizing expression is difficult to imagine, it suggests that the young are incapable of understanding the same information as adults, whereas the truth in my experience, is the opposite. Perhaps it is time to take a break.

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