Vol. 1, No. 6
ugandahealthcom@yahoo.com
November 19, 2008
What’s New? Spotlight on Malaria If you think Ugandan medical school students spend their time dreaming about greener pastures, think again. The Makerere University Medical Students’ Association has organized an International Students’ Conference on Malaria in the Tropics. The three-day event, which begins Thursday, Nov. 20, will include presentations of scientific papers, exhibitions and debates. The goal, says Ronald Kiweewa, a fifth-year medical student and the conference committee scientific chairperson is “to make a contribution to malaria-prevention in the country, as well as provide a platform to launch advocacy campaigns for malaria prevention.” With indoor spraying of DDT stalled in court, what comes next? Is compromise possible? Can both sides agree on safeguards that would make use of DDT acceptable? And if not, are there viable alternatives to DDT? Myers Lugemwa from the Ministry of Health (and conference mentor) and Steven Nyanzi, Makerere University chemist, will examine those issues in a UHCA-sponsored debate on Saturday, November 22, beginning at 2:45 p.m. The conference will be held at Katonga Hall, Hotel Africana. For more information, see Page 2 or http://conference.makmed.org/about.html
Getting Organized UHCA has two committees to plan its workshops and publications strategies – including plans to build a “virtual resource center – for the coming year. If you are interested these activities, please contact: •
For workshops: Chairperson Esther Nakkazi (nakkazie@yahoo.com) or Vice-Chairperson Patrick Ogwang (pogwang@newvision.co.ug; 0782 559638).
•
For publications: Chairperson Grace Natabaalo (nattygrace@gmail.com; 0782 508992) or Vice Chairperson Anthony Bugembe (ABugembe@nevision.co.ug).
•
For the newsletter, Editor Lydia Namubiru (lnamubiru@newvision.co.ug; 0752 628998).
You also can contact these leaders by emailing UHCA at ugandahealthcom@yahoo.com.
Also in this Issue... How America Won its War Against Malaria: Lessons for Uganda…………..............Page 2 Measles – the Next Epidemic? The World Health Organization’s William Mbabazi explains the mounting risk – and what health journalists should be doing now….…………….....Page 3
An Economic Perspective: World Bank economist Rachel Sebudde sheds new light on Uganda’s population challenge……………………………………………………….....Page 5
The Pharmaceutical Puzzle: Why Uganda’s well-designed medicine management system doesn’t work…………………………………………………………………………………......Page 6
Uganda’s Number One Health Problem The Makerere University Medical Students Association got their priorities right when they organized the The International Students’ Conference on Malaria in the Tropics, which runs November 2022. Malaria is Uganda’s Number One killer, causing up to 100,000 deaths a year – most of them children under five. It puts an enormous strain on the country’s health-care system, accounting for 20% of inpatients and 40% of outpatients in Ugandan hospitals. And that understates its real impact, since malaria contributes to a range of other problems, including low birth weight, weakness, blindness, speech problems, epilepsy, anemia, and recurrent fever. Malaria is both a major cause and consequence of poverty. The World Health Organization estimates that malaria-free countries grow 1.3% faster per year than countries still inflicted by the disease. In 2000, WHO estimated, sub-Saharan Africa’s economic output would have been a stunning 32% higher if malaria had been eliminated 35 years earlier. Here’s the conference schedule: Thursday, Nov. 20: Opening Ceremony, including Keynote Address: “Malaria, the Scope,” Makerere University scientist Moses Kamya (3 p.m.). Friday Nov. 21: • Epidemiology and Scope (8 a.m.-11:15 a.m.) • Recent trends in management and treatment (11:15a.m. – 4 p.m.) • Vulnerable Groups (4-5 p.m.) Saturday, Nov. 22: • Malaria Prevention and Control (8 a.m. – 1:10 p.m.) • Prevention and Eradication (1:10 p.m. – 2:45 p.m.) The Role of DDT in the Fight Against Malaria • DDT Use in Uganda – Dr. Myers Lugemwa (2:45 p.m.) • What’s Next? – A Uganda Health Communication Alliance debate featuring Ministry of Health medical expert Myers Lugemwa and Makerere University Chemistry Professor Steven Nyanzi, moderated by Paul Banoba, Health Programs Coordinator, Panos East Africa (3:10 p.m.) •
Closing Ceremony. Honored Guest: Stephen Mallinga, Minister of Health (4 p.m.)
How America Conquered Malaria (Hint: DDT Played a Big Role) Malaria posed a serious threat to health in North America until 60 years ago. The story of its eradication may have implications for Uganda today. During the 1940s, Americans grew increasingly concerned about the disease, which was especially prevalent in southeastern states because a number of military bases crucial in the war against Nazi Germany had been established in this malaria-afflicted region. To fight this internal enemy, the U.S. government in 1947 launched a National Malaria Eradication Program, which was led in part by a national agency called the Communicable Disease Center. The program’s main strategy may sound familiar to modern-day Ugandans: health officials applied the insecticide DDT to the interior surfaces of rural homes and in places where malaria was particularly prevalent, to entire homes. By the end of 1949, more than 4,650,000 house spray applications had been made. It worked: the number of cases dropped from 15,000 in 1947 to just 2,000 in 1950, and in 1951 the disease had vanished from the U.S. The Communicable Disease Center, meanwhile, went on to become the Centers for Disease Control. But it is still based in Georgia, the southeastern state where it helped lead the malaria fight. Meanwhile, Ugandans are debating whether to pursue the same strategy despite concerns about the safety of DDT (See: http://www.cdc.gov/malaria/history/eradication_us.htm ).
--2--
The Next Epidemic May Be Measles: Are Journalists Helping Us Get Ready? By William Mbabazi World Health Organisation My job is Disease Intelligence – or “disease surveillance,” to use medical terminology. I support the Ministry of Health in trying to predict disease epidemics, and when they occur in making sure they are detected in time, and appropriately and effectively responded to. Most epidemics, including cholera, dysentery, and Hepatitis E, are environment-related, and therefore predictable. If you find that latrine coverage is low and sanitation practices not good (no hand washing after toilet use or before handling food, and poor excreta management) you know and should expect that when rains come the bacteria that cause epidemics will have good breeding grounds. While some outbreaks like Cholera, Dysentery, Polio and Malaria can confidently be predicted, other disease epidemics, like Ebola, Marburg, and Yellow Fever are difficult if not impossible to predict. If you had asked me in June 2007 whether there would be a Marburg outbreak, I would have said no, for instance. We can get it wrong or right, but that doesn’t stop us from predicting. Why? So that we can make the population ready to avoid or abort common epidemics and be ready when they occur. The media can play vital role in this process. I invite media to engage with us before our work makes news. There are several things it can do.
One million children missed their nine-month measles vaccinations. Now, one case could set off a big outbreak. First, journalists can look at our analyses of disease patterns, and report them so that people know what to expect. The more people know about the risks and their implications, the greater the chance that epidemics will be quickly controlled once they break out. If journalists can share epidemic risk factor information (status of sanitation, sanitation practices and water quality) before outbreaks occur, my guess is that policy and decision-makers would end up anticipating them rather than trying to catch up and lead the public in trying to deal with problems after they arise. For example, we are predicting measles outbreaks in most districts in the 2008-2009 financial year because our estimate is that one million children under five years missed their nine-months measles dose and did not receive their additional dose during the 2006 measles campaigns. This means that we need only one case to light the fire of a big measles outbreak. Second, the media can help promote risk-reduction behavior. For example, the predicted measles outbreaks could be aborted if the media would lead a discourse now on the reasons for the rapid build up of unimmunised children. Are measles vaccines available in all immunizing centres? If not, what is the problem, and if vaccines are available, why are children still missing their desired doses?
--3--
The media has been very instrumental in behaviour change communication in the on-going Hepatitis E and Cholera epidemics in Acholi sub-region and Kampala respectively. The continued coverage of both epidemics in print and electronic media is indeed helpful and appreciated by the epidemiccontrol communities Third, media can help in epidemic detection. Detection commonly is considered the business of Ministry of Health and its surveillance divisions, but journalists often learn first about incidents of mysterious diseases or deaths. If you hear of a mysterious death or deaths in a particular village, tribe or area, you should report it. It may not be cause for suspicion in a journalist’s mind, but it could be in my mind. In fact, the media may see a pattern even when the traditional medical community has not. For example, we expect the media to report any measles death as a indication of a measles outbreak.
Journalists usually ask, “How many people are dying?” It would be more useful to tease out the risk factors of the epidemic spreading, and identify likely areas of intervention. During outbreaks, journalists usually ask, “How many people are dying,” or “How many are going to die?” It would be more useful to tease out the risk factors of the epidemic spreading beyond the affected areas, and identify likely areas of intervention. What are the right questions or the questions I expect the media to be asking? When I predict an environmental, sanitation-related epidemic like Hepatitis E, which we have now, the media should lead the debate on what hygiene and sanitation actions could reduce the risk of such epidemics. If I predict a measles epidemic in the next six months, the media should ask what individual behaviors can people take, and how to detect cases should an outbreak occur. Or if I investigate a rumor that there is a cholera case, the media should ask me, “What the behaviors and practices should people start changing to prevent the disease outbreak?” In short, you should be leading the way in giving the public and decision-makers the information they can use to act. Please don’t spread only rumours, and while you should hold us accountable, please recognize our intentions. When headlines only report things like “Fifth Health Care Worker Down” or “Nurses on Strike,” you convey the message that we don’t know what this disease is about. In the Ebola outbreak last year, we worked hard to find the cases, treat them, and tell the public what they need to know. But the way it was reported undermined public trust that we knew what we were doing.
You should be leading the way in giving the public and decision-makers information they can use to act. Finally, as a country we need to advocate for resources to be put aside for epidemics. We are very sure more epidemics will come. We need media on our side because we know the role media plays in civil society by informing debate for citizens and policymakers. In short, media can ensure that public has the same knowledge and same perception of risk as epidemiologists. When we predict, we want journalists to know it’s not straightforward and we may get it wrong, but the reasons for our predictions can be as important as what we predict. And if we get it wrong, journalists should ask what benefit did we gain from the effort, rather than just criticize us. Right now, epidemiologists are aware of the risks, but we don’t have gateways to make people aware of them and of the appropriate solutions to epidemics. This has to change. After all, it’s the public that bears the highest risk when epidemics happen.
Countering counterfeits Roger Bate, a director of the health advocacy group Africa Fighting Malaria, urges aid organizations to give technical and financial support to governments that maintain strict drug inspection standards. http://www.nytimes.com/2008/11/15/opinion/15bate.html?_r=1&scp=1&sq=roger+bate&st=nyt&oref=s login
--4--
Population Boom: An Economic Perspective Some see Uganda’s rapid population growth as a source of strength. If the country has more people, that means it will have more workers, and more workers will translate into more output, the reasoning goes. Right? Unfortunately, it’s not that simple, according to World Bank economist Rachel Sebudde, who addressed a UHCA workshop on population issues on October 8. While a larger population will produce more goods, the country will only be better off if output per worker increases – and that requires more capital investment, better schooling, improved technology, and production of highervalue goods. If these factors don’t increase faster than the population, the growing number of people will have to struggle simply to maintain current standards of living. Sebudde’s presentation shows that Uganda has its work cut out for it. The government has critical planning and investment to do to get ahead economically while its population surges. Government has to make huge investments in education as well as physical infrastructure like roads and machinery. It has to create an enabling environment for greater value addition to domestic products and for technological advancement in manufacturing processes. But government cannot do the job alone: the Ugandan people have to work harder too. The job will be easier if the dependency ratio – the number of people who depend on others for their livelihood – declines. That can happen if the birth rate drops or if more people go to work. But such goals are quite achievable. Sebudde cited statistics showing a dramatic drop in the birth rate in countries like Kenya, where the government has aggressively promoted family planning. And the number of working people should rise as Uganda’s huge population of children ages. Other highlights of Sebudde’s presentation include: Uganda’s population characteristics • 3.2 % growth rate - one of the fastest • 11th most populous country in Africa • 80% in rural area - 2nd most rural in Africa • Very young population with 50% of the population below 15 years of age • Highest Dependence ratio (1.12) in Africa • Situation not likely to improve over next 20 years - demographic transition yet to start! The driving factor: A stubbornly high fertility rate rd • At 6.8 births per woman, Uganda has the 3 highest fertility rate in the world, a rate that has only negligibly dropped over the past 50 years from 7 in the 1960s. • Neighbouring Tanzania and Kenya have on the other hand reduced fertility from 7 in the 1960s to 5.3 and 5.8 respectively • Other factors include the existing momentum from the young population entering adulthood and improving living conditions and life expectancy Rachel Sebudde’s full presentation with useful statistics and projections is available on request, as are the presentations from two other speakers who appeared at the workshop, by contacting ugandahealthcom@yahoo.com.
Guidance for Children Who are Left to Run Their Own Households In some African countries, including Uganda, the AIDS epidemic and war all-too-often leave children running households by themselves. Yelula U-khai, a Namibian alliance working to help societies cope with HIV/AIDS, has published a handbook for children who have to take on adult responsibilities. The handbook offers tips on such topics as caring for oneself and one’s siblings, handling money and family assets, managing a house and land, and dealing with health and illness and community relationships. It is available online at: http://www.eldis.org/go/topics/resource-guides/hiv-andaids&id=40651&type=Document
--5--
Uganda’s Pharmaceutical Puzzle:
We Have a Well-Designed Medicine-Management System, but It Is Deplorably Inefficient On paper, Uganda’s medicines management system appears to be very well designed, according to Dr. Mshilla Maghanga, a pharmacy lecturer at Gulu Medical School who spoke at UHCA’s workshop on pharmaceutical drugs on August. 27. Drug requests are supposed to move along a smooth chain from the health facilities through health subdistricts to district headquarters and finally to the National Medical Store, and supplies of medicines follow the sequence in reverse to patients who need them. In reality, what happens in practice is anything but a neat supply chain. At the grassroots, health facilities and patients are going without essential drugs, while higher up the chain, drugs are sitting unused and even expiring in the stores. The result: we have poor national health indicators and the public has lost faith in the health system. Dr. Mshilla said numerous problems combine to produce a huge gap between theory and practice: •
Inadequate pharmaceutical human resources. Only about 1.4% of health professionals are pharmacists.
•
Poorly trained health workers. In Gulu and Amuria districts for example, only 3.8% of health workers are postgraduates and 1.3% are graduates, while the majority (66.2%) only went up to O Level or lower.
•
Poor warehousing and storage of medicines.
•
Poorly implemented inventory control systems. Many health facilities don’t even meet basic inventory control requirements like having a list of essential drugs.
•
Poor logistics management information system.
•
Inefficient transportation and distribution systems.
•
Poor forecasting of medicine needs.
•
Inadequate support supervision.
•
Unavailability of medicines and low supplier capacity.
•
Inadequate national funding. Budgets FY 2004/05 and 2005/06, were 9.6% and 10.6% of the Uganda national budget respectively (both less than Abuja Declaration by African Heads of State to spend 15% of the national budgets on health). District spending on essential medicines also is inadequate.
•
Poor procurement procedures, cash flow problems and inefficiency at NMS cause delays in the procurement of essential medicines. It may take 60 days to deliver orders.
•
Poor selection and quantification of medicines and lack of prioritization.
•
The increased demand for particular medicines like cotrimoxazole due to its additional use in the prophylaxis in HIV/AIDS patients
For Mshilla Maghanga’s full presentation or those of other speakers who appeared at the workshop, contact: ugandahealthcom@yahoo.com.
To be added to our mailing list, contact us at ugandahealthcom@yahoo.com --6--