Broadly speaking, public health should be Africa's number one priority
What you need to know:
- The unfortunate thing about Africa is its failure to learn from the past, especially from Europe that was once ravaged by bubonic plague outbreaks.
- Pfizer claimed to have permission from the local hospital to conduct its experiment, but the approval letter was said to be a forgery.
- In particular, people want their governments to improve the quality of hospitals and other health-care facilities and deal with the problem of HIV/Aids.
- We often fail to fully appreciate the total cost of sick people in looking at direct cost, yet the days they miss from their workplaces are costs.
Sometimes in a crisis, broad thinking is obscured. The Ebola crisis in West Africa is one such crisis.
We think we are safe if the West Africans are confined to their own countries. Yet Ebola is not the end of infectious diseases.
The rate at which we are setting the stage for opportunistic diseases, including infectious ones, is worrying. Our priority now should be the role of public health in Africa.
The majority of African media are rushing to prescribe short-term interventions, such as avoiding handshakes or hugging, but these are not sustainable solutions.
Several factors contribute to the emergence of new diseases like Ebola. These include poor or non-existent public health facilities, crowded and unplanned urban settlements, interactions with the animal kingdom, and other sources that have not been established yet.
KILLED 100 MILLION
The unfortunate thing about Africa is its failure to learn from the past, especially from Europe, which was once ravaged by bubonic plague outbreaks.
Ananya Mandal noted in his article “Human Diseases Caused by Viruses” that the 1918 flu pandemic, commonly referred to as the Spanish flu, spread across the world like HIV/Aids.
It was caused by an unusually severe and deadly influenza A virus. The victims were often healthy, young adults in contrast to the weakened and elderly, who are the usual victims.
It killed around 100 million people or at least five per cent of the world's population in 1918.
Studies show that the Influenza A virus causes influenza in birds and some mammals, and is the only species of influenza virus A. Some isolates of influenza A virus cause severe disease in domestic poultry and, rarely, in humans.
Occasionally, viruses are transmitted from wild aquatic birds to domestic poultry, and this may cause an outbreak or give rise to human influenza pandemics.
EXPERIMENTAL MENINGITIS DRUG
Most of these outbreaks have no medicine. In most cases researchers are forced to use drugs that have not been approved. An analysis, "Ebola outbreak: Africans understandably wary about promised cures", by Daniel Schwartz of CBC News, reveals a 1996 drug experiment that went awry in Nigeria.
Schwartz says when a meningitis epidemic was under way, the American pharmaceutical company Pfizer arrived in the hot zone in Kano. Its representatives immediately set up their clinic next to the makeshift tents of a hospital then staffed mostly by Doctors Without Borders.
Meningitis, an inflammation in a membrane surrounding the brain or spinal cord, affects mostly children, and, without treatment, about half of those infected will die.
Pfizer had a new treatment that it wanted to test, so its doctors gave Trovan (floxacin) to about half the 200 children they treated, while the other half received an approved drug for meningitis. About five per cent of the patients taking the experimental Trovan died, while some others were left blind, deaf and/or paralyzed.
DRUGS WITH NO MARKET
In the aftermath, the US Food and Drug Administration refused to approve Trovan. Hundreds of Nigerian parents sued Pfizer, and the company eventually settled in 2009. (Its position was that it was the disease that had caused the deaths and other conditions.)
Pfizer claimed to have had permission from the local hospital to conduct its experiment, but the approval letter was said to be a forgery. Pfizer claimed it had informed consent from the patients’ families but could not provide written proof.
Clearly, drug manufacturing companies have no incentive to spend resources on drugs that have no market and are only relevant during a crisis like the one we are in at the moment. Europe has largely dealt with breeding grounds of such outbreaks.
That leaves Africa with two options, that is, adopt and maintain modern living standards with strict public health regulations for every citizen, or spend a great deal of resources on research to develop the capacity to deal with such epidemics.
Let me now look at some of the causes that we have control over and perhaps challenge you as the reader on what we need to do collectively to get our continent’s public health in line with other parts of the world. In my foolish approach to research, I asked myself this question: Where do viruses come from?
Several research papers converge on what Dr Ananya Mandal summarizes in the table below arguing that there are several viruses that have an animal or plant reservoir from where they affect humans.
Table 1: Some of the common reservoirs of viruses.
| Virus | Animal reservoir |
| Influenza | Birds, pigs, horses |
| Rabies | Bats, dogs, foxes |
| Lassa and Hanta viruses | Rodents |
| Ebola and Marburg viruses | Monkeys |
| HIV-1 and -2 | Chimpanzees, monkeys |
| Newcastle disease | Poultry |
| West Nile virus | Birds |
Source: Ananya Mandal, MD
Public Health
In my view, the answer lies in what we do with our public health. Prior to the Ebola outbreak, the Pew Research Center, in a survey conducted between March 6, 2013 and April 12, 2013, in six African nations established that concerns about public health are widespread in sub-Saharan Africa, and there is considerable support in the region for making public health challenges a top national priority.
In particular, people want their governments to improve the quality of hospitals and other health-care facilities and deal with the problem of HIV/Aids. The survey also finds broad support for government efforts to address access to drinking water, access to prenatal care, hunger, infectious diseases, and child immunization.
Table 2: Public Health Priorities
While walking within Mukuru kwa Reuben (one of the shanty areas of Nairobi) on a research mission, I saw pigs, chicken, goats and rats feasting on solid waste from the shanty. Nearby were kiosks selling all manner of things.
There were no public health officials in this breeding ground of future outbreaks. And no one will be safe because most of the help the rich in posh neighbourhoods have resides in such shanties.
It is no longer a poor man’s burden. It is our burden. We are in it together. It is perhaps cheaper to clean up, and provide running water and modern plumbing to the poor rather than suffer the deaths that may arise out of some unknown infectious epidemic.
ANIMALS IN URBAN AREAS
The majority of urban areas have by-laws regulating the keeping of animals in urban set-ups, but they are not enforced. For the good of all, we need to keep animals that we cannot manage out of residential areas.
The least we can do is to create the awareness of the dangers we generate when we do not adhere to acceptable hygienic standards.
Our culture is such that we love pets but lack the drive to provide for them in terms of keeping up with vaccinations or grooming, which begs the question: Why keep the pet if you cannot maintain it?
DEVOLUTION FAILURE
In the past few weeks we have seen the level of incompetence within county governments to manage health care. To save face, the governors must convene and surrender health-care services to the national government as a sign of good leadership. They can take up the challenge of managing health care once they develop capacities.
As it is at the moment, they continue to disenfranchise doctors whose morale is at its lowest owing to poor pay and work conditions. Some drastic decisions must be made to change the deplorable conditions of our health facilities.
We often fail to fully appreciate the total cost of sick people in looking at direct cost, yet the days they miss from their workplaces are costs. Health economists are not part of our health-care system, which may be the reason why even the national Treasury or Parliament fail to understand the full impact of having a large number of unhealthy people.
Until we appreciate the full cost of health care, the focus on preventive health care or any reforms will fail.
There is need to declare health care a national crisis such that we suspend the Constituency Development Fund (CDF) (which has become a cash cow for some MPs) and utilize the resource to build the infrastructure for a national health-care system as a priority.
AN AUDITOR DISBURSING MONEY
We also need to leverage public-private partnerships (PPPs) for infrastructure development. We must aim to build first-class facilities and management systems that will lower the cost and stem health tourism to India that runs into billions of shillings.
Sometimes a tragedy like Ebola is what it takes to comprehensively deal with our public health system. The CDF, which was meant to devolve resources, has been overtaken by the creation of counties. The CDF kitty is sufficient to build our health-care infrastructure if supplemented with private-public partnerships.
In any prudent financial system, an auditor should not be disbursing money. What our Parliament is doing with CDF is like keeping a lion in a goat’s pen; in other words “Paka haachiwi kitoweo kukilinda”.
It is the collective will of the people to ensure that public health is a priority.
Paul Farmer said, “But if you're asking my opinion, I would argue that a social justice approach should be central to medicine and utilized to be central to public health. This could be very simple: the well should take care of the sick.”
Dr Ndemo is a senior lecturer at the University of Nairobi's Business School, Lower Kabete campus. He is a former permanent secretary in the Ministry of Information and Communication. Twitter:@bantigito
