Archive for June, 2011

Monkey drinks Cola in Addis Ababa

A monkey drinks cola in Addis Ababa

By Dr Jackie Spiby

Hello from Addis Ababa.

It is a warm and sunny morning. By lunchtime it will be hot, but not too hot as we are 2,400m high and there is usually a breeze. When I go out it will be dusty, smelly and, if I noticed it anymore, the air will be polluted. This is mainly due to the huge volume of taxis, buses and lorries, most of which are ancient and belch out dark smoke which hangs around the city. I walk everywhere or go on a crowded, filthy line-taxi; so am I green? I came on a plane so blew my green travel limit and I use plastic water bottles – well I have to as I can’t drink the water but I do boil and filter so I reuse the bottles. Plastic bottles are everywhere.

I am a VSO volunteer and working in a local NGO (though virtually totally funded by external donors).  After 32 years in the NHS it was time for a change. For me that is, not the NHS because, as we know, that happens all the time. It took some time getting through the VSO process especially as my husband is here as an accompanying partner. Attending the assessment day together was a new experience. Try doing a group activity (you know one of those management games) with your partner. VSO then sends your CV out to local VSO programmes for them to see if they want you. You don’t get a choice; you just get to say yes or no to an offer. The first one was way outside of my experience, the next we had to go in five weeks; the next wasn’t viable for my husband.  Despair; but finally Ethiopia came up, an HIV organisation at national level and a country of spectacular scenery with mountains. It wasn’t the Far East which was my preference but we are here and at some point we will get to the mountains.

I am working in an organisation called the Network of Networks of People Living with HIV (PLHIV) or NEP+ for short. The HIV epidemic in Africa is heterosexual. When it emerged in the early ’90s there were no HIV services.  PLHIV started to form groups to help themselves and a few very brave souls (many of whom are dead now) came out and said that they were positive and demanded acceptance and support. My organisation arose out of the formation of these groups. There are nine regional networks, two city networks and three national ones with some 400 local networks. Civil engagement is one area of activity but primarily they are organisations that help provide prevention, treatment and care as well as projects to increase skills and employability. However, that is changing as the government starts to provide a health service. So, as ever, an organisation in change.  To think I didn’t know about the Global Fund six months ago and now I can quote the rules chapter and verse.

HIV is about poverty here, the treatment may be free but food and shelter are not and many PLHIV can’t afford the basics. Nor is the treatment for opportunistic infections free, so TB and malaria are the main killers.

So here I am. NEP+ is some 30 people – all Ethiopian, except me. It is primarily male, except me. Originally the organisation’s staff were PLHIV. As the donors started to require financial statements, governance and the like, the professionals arrived. Now the balance has changed. Is that right? Should there be positive discrimination toward PLHIVs? Can someone who is sero-negative really know or understand what it is like to be positive or even what it is like to live in a family affected by HIV? All questions that I remember discussing in the ’80s when working at the King’s Fund. All answers gratefully received.

Now more and more HIV infected people are getting treatment and living. But there are still 14,000 HIV-positive babies born a year. In the UK and US the numbers are way below a hundred. Why? Many women don’t use antenatal services or won’t get tested. Why? Lots of reasons but for some their husbands won’t let them, accessing services is too difficult or their families tell them to use traditional services. Even if a woman is diagnosed, follow up is logistically difficult and complying to the full treatment and breast feeding regime complex in a developed country, let alone a rural village with no water or electricity. The net result is a take up of about 12% of prevention-of-mother-to-child-transmission treatment. One of the worst levels in Africa. Tragedy. All those avoidable deaths and HIV+ kids, let alone the number of women who don’t get treatment. The number of orphans is horrendous. The international, political voice on this one just isn’t there.

VSO volunteers work in local organisations and are paid a stipend which is equivalent to local salaries. So I am paid the same as our drivers, but I do get accommodation. That means we live and work in the community much more than the majority of ex-pats (called Farangis here) who work for international NGOS, the private sector or embassies. I think I am going native as I am starting to really empathise with my colleagues as we try to use the EU process for submitting a bid on a slow dial-up computer link or listen to a well-meaning expert from a big international NGO tell us we must do more on civil rights. Of course we should but at the risk of immediate shut down. There is a law forbidding NGOS to speak about civil rights. A classic case of can you do more inside the system or outside.  Only here is it outside the system but in the country or outside internationally? Oh I have a lot of learning to do.

Public health issues are everywhere including my diet. My hips are vanishing as my diet has drastically changed to minimal dairy with fruit, veg and carbs instead. Having had a fractured hip a couple of years ago I am a bit concerned about my calcium intake. I was taking supplements in the UK but stopped when there was a report on increased incidence of heart disease. I am eating injera, the local, unique dough that is eaten with everything. It looks like a chamois leather but isn’t too bad and is suppose to have some calcium in it.  Should I get Steve (my husband) to bring some calcium tablets back when he visits the UK in the summer?

Must go as visiting a local community project for orphans. More to come.

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By Andy Beckingham, ex-DPH and public health consultant now living and working in India

Indian back street

Indian back street

I spent much of 2010 in South India on sabbatical with Indian Institute of Public Health. Would my UK experience be useful? Or irrelevant in India? I made new friends and networks, loved the food, the heat and the work. I was incredibly lucky to find a great boss. Found myself helping identify the ‘burdens of disease’ for one state (pop c80 million) and working with the Indian government to focus primary care and work on social determinants, to address health needs – and often failing too. I worked on maternal mortality and discovered how hard it is to change things when social determinants are complex and women undervalued. My boss and I were asked by the government to assess the impact of climate change on the country’s health, and our contribution went into Climate Change and India: a 4×4 Assessment. It helped that I’d been a DPH in England, but getting this kind of work experience was mostly just luck. I returned briefly to a snowy UK, its NHS workforce shell-shocked to find their skills on the Government’s scrapheap. Hmmm – back to India…

2011 – I woke as the dawn appeared as a thin orange line over the Arabian Sea and the plane flew in over the Western Ghats. In 2010 I had met the CEO of a maternity hospital who’d asked if I’d like to set up midwifery training. Are you kidding?? Yes!! So In 2011 I find myself working in a hospital seriously dedicated to improving clinical quality. And in a world of private health care, nevertheless providing free health care for the poorest women. Our Consultant Obstetricians work 7am-9pm and sleep in the hospital when on call, to be quickly available when women have difficulties. A small village hospital 100 km away and run by nuns needed doctors, so our CEO is lending them two registrars for free and I’m helping them plan cervical screening and incontinence counselling to complement their obs & gynae sessions. Public health work here is like…  SO interesting, Dude…  I’ve made links with an NGO in the city’s biggest slum (estimated population… a million? We have no demographic nor epidemiological data) with no primary health maternity care there. Pregnant women walk 3km in 90ᵒF to the nearest private hospital. We plan to provide a free doctor. They’ll have their work cut out…

The maternity hospital I work for managed 5,000 births last year, 65% of them ‘high risk’. We’re developing a programme to train nurses to become professional midwives who will manage the normal births and free the obstetricians up to do the risky ones. India doesn’t really have midwives, so we will pilot their training and work, and evaluate whether they contribute to better maternal outcomes. So in 2011 I find myself writing the curriculum, setting up the training, plus a midwifery exchange programme with South Africa, London and Toronto. Almost every week another really interesting health issue arises. I love it here… want to come too?

PS: Spot the health inequality issues in the photo to win free biryani, bangles and a public health internship.

PPS: No salary available, find your own plane fare.

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