OpenForum – a blog by the Health and Human Rights community

In resource-constrained settings like Kenya, “more than 90% of children with sickle-cell anaemia die before the diagnosis can be made,” most likely due to opportunistic bacterial diseases. Two of the most common infections, Streptococcus pneumoniae and Haemophilus influenzae, are preventable or treated readily in developed countries.

A recent study published in The Lancet underscores these health inequities suffered by children in sub-Saharan Africa. The report, “Bacteraemia in Kenyan children with sickle-cell anaemia: A retrospective cohort and case-control study,” examines retrospectively the prevalence, diagnosis, and treatment of bacterial illnesses associated with sickle-cell anemia in Kenya.

At the Kilifi District Hospital in Kenya, the researchers collected and studied blood cultures from approximately 38,000 children under 14 years of age who were admitted between August 1, 1998, and March 31, 2008. They identified approximately 2,000 cases of bacterial infection. Sickle-cell anemia was identified in over 100 of these cases, but three-quarters of these children did not receive this diagnosis until admission for a bacterial infection.

Although studies show that antibacterial prophylaxis and vaccination can improve the prognosis for people born with sickle-cell anemia in developed countries, few guidelines exist in Africa that would improve the detection and treatment of the disease and its related infections. According to the researchers, “few studies have described the bacteriology of sickle-cell anaemia in sub-Saharan Africa despite the fact that more than 200,000 African children are born with this disease every year.” The dearth of data, most likely due to underreporting, contributes to the stalled development of evidence-based guidelines that could save thousands of lives.

Vaccines against Streptococcus pneumoniae and Haemophilus influenzae, the most common causes of infection among children with sickle-cell anemia, are administered regularly in developed countries. The uptake of such preventative measures has been slow in Africa due to funding priorities for other pervasive diseases such as HIV and malaria. A Reuters article about the study mentions that the Global Alliance for Vaccines and Immunization (GAVI) currently provides an effective vaccine for Haemophilus influenzae type b (Hib) to 35 African nations and hopes to roll out an improved pneumococcal vaccine across Africa in the next few years.

The Lancet study results suggest that “bacterial infections are a major cause of morbidity and mortality in children with sickle-cell anaemia.” Unless greater attention is given to identifying and treating the disease in developing countries, sickle-cell anemia will continue to contribute to child mortality. Targeted interventions would save lives and lead one step closer to reaching the Millennium Development Goal of reducing mortality in children younger than 5 years old.

A number of non-traditional practices are arising in poor and developing communities to fight high maternal mortality rates. One example that has taken hold in many African countries is the use of non-physician clinicians (NPCs) – health care providers who are not licensed physicians but who still provide substantial medical care. The retention rate of these types of practitioners tends to be higher, and the cost of training and deployment much lower, than those of doctors.

At a recent conference, health delegates from 42 countries agreed to implement a new strategy that trains NPCs in emergency obstetric surgery to address the lack of health care workers. Along with other developing areas, most African countries are suffering from a significant lack of medical professionals. This shortage is particularly implicated in the high rates of maternal and infant deaths during childbirth. The WHO has estimated that in sub-Saharan Africa alone, there is a shortage of nearly 1.5 million health care workers; women there face a 1-in-13 risk of dying in childbirth. Most women are unable or unwilling to access medical facilities or workers, even during emergencies; for example, in Ethiopia, only 6% of all births occurred in a health facility.

By expanding the number of NPCs and training them in surgical childbirth procedures, it is hoped that more births will be attended by trained health care workers who can assist women during emergencies. A program in Mozambique that trains midwives in surgical techniques has already achieved significant results. The country is on the way toward meeting several of the UN’s Millennium Development Goals, particularly those surrounding maternal and newborn health. Read more

Many medical professionals and politicians looking toward alternative methods of providing health care are finding examples of communities within the US and in the developing world that have been able to give quality care without skyrocketing costs.

A June article in the New Yorker by Atul Gawande, which is reportedly required reading at the White House, examines the costs of health care by looking at the most and least expensive health-care markets in the US. In particular he studies McAllen, Texas, which has one of the highest costs of medical care per person in the country, and Rochester, Minnesota (home of the Mayo Clinic), which has among the lowest. Rochester also provides some of the best quality health care in the nation. Gawande’s findings led him to conclude that the Mayo Clinic system, which pays doctors an annual salary to keep them from treating their practices like “profit centers”, and emphasizes a peer-review process to improve quality of care, are the best hope for improving American health care. This requires breaking the “untenably fragmented, quantity-driven” systems that are becoming the norm in US medical care.

Gawande notes at the end of his piece that the decisions that need to be made about America’s health care system are greater than the public versus private insurance debate; rather, they involve a total reorganization of the health system. Enacting the principles already in place in the lowest-cost, highest-quality medical institutions in the country – removing any financial incentive for doctors to order unnecessary procedures and taking collective responsibility for patients – require a significant reordering of our priorities.

Others are also looking outside of the political discussions that focus on either “raising taxes or cutting care,” instead seeing a better way: “redesign.” Medical professionals from ten communities across the country with below average health spending and above average health outcomes recently traveled to Washington DC to discuss how changes they have implemented have lowered cost without reducing quality. Gawande, one of the meeting’s organizers, explained that change in these communities occurred quickly, as “[h]alf of these communities used to be high cost and transitioned to low cost over the last decade,” suggesting that national reform is also possible. Read more

Community health worker administering medicine in Rwinkwavu. Photo courtesy of Partners in Health.

[Editor's note: In addition to Dr. Binagwaho, Dr. Fidele Ngabo, Cathy Mugeni, and Niloo Ratnayake also contributed writing to this post.]

Access to care in resource-constrained countries has three major barriers to overcome: finances, infrastructure, and geography. Community health workers (CHWs) are an unavoidable solution for both infrastructure and geography. The Government of Rwanda has recognized that CHWs are necessary in order to improve access to health in rural communities. By using CHWs, with their approach to health at the community level, Rwanda hopes to solve 80% of health problems in the country.

Rwanda has set up a system where each village (100 to 150 households) elects two volunteers to act as CHWs for the general population. Because each community votes on one woman and one man to serve the village in this capacity, becoming a CHW is now a position of respect, raising gender equity throughout Rwanda.

These two CHWs are then trained to monitor growth and development in children, to care for people living with HIV, and to refer sick patients to the nearest health facility. Their training is designed by the Ministry of Health, which enables them to provide services in a harmonized manner throughout the country. By sensitizing the local village and making themselves available, they improve access to care; because of CHWs, a greater number of previously unreachable Rwandan citizens now have access to care. The CHWs trained this year to provide services to their villages are trained to treat certain diseases using amoxicillin and to distribute family planning tools (condoms, contraceptive pills, and injectable contraception). Read more

There is a growing trend around the world of children being accused of witchcraft. Once accused of witchcraft, a child is punished, beaten, starved and sometimes killed to “cleanse” her or him of supposed magical powers. What is pushing the trend?

The UNHCR report Witchcraft allegations, refugee protection and human rights: a review of the evidence points out that witchcraft provides an answer to the question “why me?” when misfortune strikes. Unfortunately for many areas in Africa and elsewhere in the world, misfortune seems to be striking with vengeance. Particularly in countries where the people have been scarred by war, famine, economic collapse, death, and HIV infections, there are many “why me?” questions to be answered. As Father Horácio Caballero, director of a shelter that cares for children accused of witchery in Angola, says, “when AIDS begins to kill, someone in the family gets blamed for it.” Other children in Angola have been accused of transforming into animals and eating crops at night. Yet scientific analysis found that late rains had caused poor crop yield during that period.

Some common traits in children accused to have witchcraft are: stubbornness, learning disabilities, physical disabilities such as epilepsy, unruly behavior and not taking school seriously. Many of these traits deemed “witch-like” are usually considered normal adolescent behavior in the West. Children suffering from disease such as AIDS and malaria are also prime targets of witchcraft accusations. Read more

Touring Africa in May, Pope Benedict XVI provoked controversy when he told an enthusiastic crowd in Cameroon that condoms are an ineffective solution to the spread of HIV. His words sparked a global reaction, opening international discussion about the use of condoms and the Pope’s impact on health and social behavior. The heated response raises a provocative question: do the Pope’s words promote the violation of human rights?  Does the vocal distribution of condom misinformation impede the listeners’ right to knowledge?

This first explicit statement from the Pope on the subject was congruent with previous Vatican statements that moral and devout abstinence, in place of condoms, should be the primary prevention strategy. However, Pope Benedict went further, claiming that distribution and use of condoms increases the problem and can in fact spread the virus. The scientifically incorrect statement, which conflicts with knowledge on the proven effectiveness of condoms, jeopardizes the human right to “share in scientific advancements and benefits” as written in Article 27 of the UDHR. In a global outcry, health officials and religious leaders asserted that the Pope’s disregard of scientific evidence is extremely dangerous given the strong influences that Catholicism and its leader have in Africa. Read more

A new campaign in Cameroon is seeking to bring more attention to sexual violence against women by encouraging survivors of rape to talk openly about their experiences. This campaign, led by the German development group GTZ, focuses on raising awareness of rape and incest, subjects rarely discussed publicly. GTZ estimates that as many as 432,000 women and girls were raped in Cameroon in the past 20 years, one out of five by a family member. To address this widespread violence, the campaign’s opening ceremony in the capital Yaoundé featured approximately 200 rape survivors; many of these women and girls publicly shared their stories. It is hoped that more open and public discussions of the experience and consequences of rape will shift societal views that tend to trivialize sexual assault.

The African women’s organization Akina Mama wa Afrika, which means “solidarity among women” in Swahili, met recently in Kampala to discuss new efforts to prevent violence against women in conflict and post-conflict areas of Africa. This group is seeking to improve legal and judicial systems to better protect the rights of women. They believe improved documentation of women’s experiences is the first step, as there is a critical lack of statistics surrounding these crimes. “Shame constrains many women’s actions,” says Annie Chikwanha, Senior Fellow at the African Human Security Initiative Institute of Security Studies. “Most times you have to seek permission of men to access the woman’s voice. Men insist on listening to the conversation. So the women feel constrained…” Instead, Chikwanha says, “it is women who suffer these atrocities so they should talk about them instead of a third party who can distort the information…let us empower women with skills to have these experiences documented.” Read more