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Gelada baboons
Move along there: Gelada baboons

By Dr Jackie Spiby

We are still here in Addis Ababa. We have survived the rainy season and the sky is blue again.

Many of you will have seen the news about the famine in the south east of Ethiopia where it borders Sudan and Kenya. Sitting in Addis, it is as difficult to understand the whole story here as it is at home. We pick up the news and some of the debate from the BBC when the internet is working. When we travelled to the south recently, everywhere looked really fertile and verdant as it was just after the rains. But at work I do hear about problems with food-aid delivery and families that can’t feed their children.

As recipients of Global Fund money, my organisation has to have pristine financial arrangements. The management audit letter we received recently could have been one found in any PCT. By the way do PCTs still exist? The only difference was that they were querying why a goat had been bought. I recently found myself on an appointments committee for an internal auditor – something I have managed to avoid in the UK. Amazingly my interviewing instincts rose to the fore. I was delighted that my first choice was the same as the finance director’s. It did help that the interviews were in English. So, another country another culture but actually much is the same.

We took a few days off to travel north to trek in the Simien mountains. Ethiopia lies in the East African Rift Valley so much of the north and central areas are hilly in stark contrast to the desert areas bordering Sudan and Somalia. We were walking at three to four thousand metres and were surprised that it was still scattered with villages, and, wherever we went, small children were keeping an eye on the cattle and sheep. They said they went to school but I wasn’t really convinced.

Walking into a BBC crew filming the gelada baboons was quite surreal. We had just stopped to put on our macks as it was raining when we heard a very posh voice asking if we could move please as they were trying to film the baboons running down that particular hill. If you ever see a documentary on these baboons in the Simiens we were there, and we saw the locals on the other side of the hill ‘encouraging’ the baboons to move.

One of my areas of work is developing a volunteers’ strategy. Not international volunteers but local volunteers. PLHIV associations are similar to charitable organisations in the UK so their boards are all volunteers and most of the programmes workers are also volunteers. However they do get expenses. The latter get 206 birr a month for travel. That is £7.60. In the focus groups they tell me they do it for humanitarian reasons. However when I asked if they also had paid work, they said it was hard to get work as they were HIV+. So what is a volunteer? I really enjoy the focus groups: however formal I try to make them, we have to have a coffee ceremony, and they usually end with music and dancing. The highlight last week was meeting a 22-year-old woman who finished school at grade 6 but was carrying a beautiful, chubby smiling baby who everyone proudly told me was HIV negative.

Am I making any difference? Not an unusual question for anyone in public health. I’ve been asking it my entire career. I’d better get back to work and make sure that I am.

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By Dr Lucy Reynolds, Visiting Research Fellow, London School of Hygiene and Tropical Medicine, University of London

  • Dr Reynolds has worked in Haiti in 2006-07 and 2007-08, and in the aftermath of the Sichuan and Banda Aceh earthquakes.

After a 7.0 earthquake with 30 aftershocks, close to the surface and to the capital city, much of Port-au-Prince is now rubble.  Although this just attains the category of major quake, in terms of destruction and casualties, it is one of the worst ever.  This is partly because of the lack of implementation of construction standards: Port-au-Pierre’s mayor estimated a year ago that 60% of its buildings were unsound.  Haiti’s development has followed a model which stresses private-sector actors and has not built a state apparatus equipped to undertake such functions to protect the population.  Corruption is another major reason for unsafe building practices: appropriate construction materials are substituted for inferior to increase profits, some of which are then available to arrange that regulations will not be enforced.  Such problems were blamed for the high death toll among schoolchildren in Sichuan in the 2008 earthquake.  In Banda Aceh, 2004-5, few buildings escaped damage other than mosques and Dutch colonial dwellings, both of which had, for different reasons, been soundly built.

TIME IS RUNNING OUT

The International Federation of the Red Cross has an active disaster preparedness programme in Haiti, and they were among the first responders for the rescue effort. They have now been joined by teams from many countries, but an almost complete lack of heavy equipment such as cranes has prevented many rescues.  Although presumably the US military could import such equipment, soon it will be too late for most of those still trapped; dehydration and/or crush syndrome will result in such severe renal damage that recovery is impossible.  Those whose limbs or torsos are trapped should be freed under medical supervision, in order to protect their kidneys.

INADEQUATE HEALTHCARE SERVICES

Many of those injured continue to wait for medical attention, and by now, are developing infections in open wounds.  Eight of Port-au-Pierre’s eleven hospitals collapsed, including one previously supported by a Médecins Sans Frontières mission, and several field hospitals have been set up as part of the international aid effort.  In Haiti, most health care is either costly private sector provision or malfunctioning because health staff are irregularly paid and supplies of medications and consumables are intermittent and inadequate.  Because of gang warfare, parts of the city are too dangerous for providers other than international NGOs and faith-based organisations. So, while international health interventions will be well funded for now, after the emergency phase health care provision is likely to be even more inadequate than previously, which could have ongoing public health consequences in the city.

WATER SHORTAGES

By the 17th, the issue of drinking water had emerged as the most urgent need for most people affected.  At the best of times much of Port-au-Prince lacks access to piped water.  In Haiti, the state is not in a position to provide services to households, and the private sector solution for ordinary Haitians is to sell drinking water in small plastic pouches containing about 200ml/time; people can also buy drinking water by the gallon for their homes.  As many of the 300,000 newly homeless have come from plumbed-in buildings, and will now be forced to depend on this system, there could be significant shortages.  It can be assumed that since a market solution has been put in place for drinking water, if demand increases price is likely to increase in the short term, before other supplies come on stream through existing vendors and relief efforts. Action on sanitation is also needed, for those in temporary shelter now, and in the future for those whose homes are defunct.

DEATH TOLL

The Red Cross estimated 3 million people displaced and 50,000 dead, but by the 16th 50,000 bodies had already been retrieved. The estimated death toll is rising toward 200,000.  Bodies have been put out in the street for relatives to collect, but the MINUSTAH peacekeepers are now moving them to a central collection point.  Some are by now unrecognisable, and some will have no relatives to collect them due to death, injury, displacement or penury.  In general, there are not usually major health consequences from the presence of corpses, but some risks exist as decomposition proceeds; fortunately it is winter in Haiti.  Social repercussions could result if corpses attract rats, wild dogs or carrion birds.  Sooner or later mass graves are needed.

OVERCROWDING INCREASES DISEASE RISK

While the dead may not create much disease, the same cannot be said of the 300,000 now homeless people in Port-au-Pierre, much of which is a shanty town with inadequate services.  Overcrowding carries risks of measles, diphtheria, whooping cough and meningitis outbreaks, as well as the threat of water-borne and water-scarce infections, and enhanced spread of TB. At least cholera is not endemic to the island!  An immunisation programme for key disease threats, particularly measles is urgently needed, because its interaction with malnutrition boosts rates of consequent blindness and death.

MALNUTRITION AND FOOD AID

Malnutrition is likely to be a major issue in the weeks to come: Haiti has been receiving food aid for so long that its indigenous agricultural base has fallen away, unable to compete with free produce. This has led to a dependence on imports which may be a difficulty as damaged port infrastructure may require development of new supply lines, at the same time as aid deliveries tie up functioning transport routes and vehicles.  Road condition within Haiti and to the Dominican border is dreadful, and so private sector food provision may not cope with the demand, meaning that food aid could be critical for more than those made destitute by the earthquake.

HIV RISK

Haiti has the highest HIV prevalence in the Western hemisphere, and population risk in an emergency situation will usually increase due to more mixing of people from different communities  and to a psychological reaction to disaster and bereavement which resulted in a baby boom nine months after the Asian tsunami.  In addition, displaced people living with HIV may suffer interruption to their antiretroviral treatment, thus becoming not only more vulnerable to infections including TB, but also more infectious to others.  A condom distribution and HIV education intervention in displaced camps would be timely. It is to be hoped that someone will think to provide formula milk and clean water to HIV+ new mothers, otherwise vertical transmission could increase also.

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By Dr Alex Gatherer

Consider some of the facts relating to prison health.  The majority of prisoners, some 80% or so, have some form of mental ill health, and between 5-10% have serious mental illness, which requires specialist care in suitable facilities.

Furthermore, in any community, the local prison at any one time will hold a disproportionately high number of non-nationals and minority ethnic groups, of people positive to HIV and Hep C, of people with educational and social skills deficiencies, of those addicted to some form of substance addiction, of those with serious communicable diseases and of those previously hard-to-reach in our cities and towns.

In most countries, including our own, this high needs group will be detained in old premises with inadequate facilities for meaningful activity and recreation and often in overcrowded conditions.

And the majority of prisoners will be out of prison and back in their home environments on the streets in our communities often after only a short time.

‘Statistical compassion’ is one of the unmentioned skills required of top quality public health practitioners.  We must be able to look behind the statistics and see the suffering, the unmet needs and the social injustices amongst the individuals who make up the overall figures that are so central to the reports we write.  Without ‘statistical compassion’, how can we make sure that we take into account, in everything we do, those who are in greatest need?

Public health has a choice. We could ignore the above, as we did for many years and waste any opportunities to help a vulnerable high risk group. Or we could realise that it is in the interests of public health as a whole to prevent our prisons from being focal points of disease.

We could also realise that the right to health applies to all.

  • Dr Alex Gatherer is Fellow of the Faculty of Public Health. In November 2009 he was awarded the American Public Health Association’s Presidential Citation for his work in improving health in European prisons.

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