African Expertise Key to Stopping Ebola – Then and Now

African Expertise Key to Stopping Ebola – Then and Now

An Ebola outbreak in the eastern part of Democratic Republic of Congo (DRC) is once again straining Africa’s medical resources.

Prospects for progress are due in large part to  lessons learned from the 2014-2016 outbreak in West Africa, which caught global health officials off guard and killed 11,000 people. One lesson that became clear was that foreign expertise cannot protect African communities from Ebola or other outbreaks of infectious disease. African health capacity and expertise is essential.

I was a member of the EpiAFRIC team that evaluated the response of the African Union (AU) to the West African epidemic. The AU had recruited over 800 volunteer medical experts from across the continent to combat the epidemic raging across Guinea, Liberia and Sierra Leone. In its wake, we travelled extensively through the affected areas, interviewing medical personnel, community leaders and people who had lost loved ones to the disease.

In Guinea, we found that 84 percent of AU volunteers were from the DRC, which had already dealt with eight Ebola outbreaks of its own. One doctor told us how they had turned around a desperate situation. The AU team was volunteering at an Ebola treatment center built from scratch, only to have it sit empty. At the height of the epidemic, families kept the sick and dying home, even as the disease spread.

Then, one day, a desperately ill woman was carried to the center. Despite her dire condition, the doctor believed she could be saved. He rallied the medical team to provide the best possible care – medication, food, hydration, compassion – and the woman slowly recovered.

It was a turning point. People began to bring their loved ones to the center. And when they did, they saw health workers who looked like them. They were not foreigners, but Africans who understood their cultures, who delivered expert care and who they could trust.

It was clear to me that African capacity and expertise were crucial to containing and ultimately ending the worst Ebola outbreak in history. Today, the head of the AU’s 2014 Ebola medical mission is on the ground fighting the outbreak in the DRC. The World Health Organization has also mobilized quickly to contain it.

Yet, even such an urgent response may not prevent another Ebola disaster—either with this outbreak or with the next. What we need is not only boots on the ground when a crisis hits, but greater African health care capacity embedded into our health systems.

Although there were early signs that the rapid response to the current DRC outbreak is helping to contain its spread, the World Health Organization worries about complicating factors such as security for health workers – including vaccinators – in an area of conflict.

Prevention is the best solution. The best way to build preventive capacity is through implementation of Universal Health Coverage (UHC).

UHC removes financial barriers to quality healthcare and encourages equity. It means that individuals and communities can receive the basic health services they need, without economic hardship. It includes the full spectrum of essential services: health promotion, prevention, treatment, rehabilitation and palliative care.

Of course, it will be costly. But in the end, it will not only be life-saving, but also cost-saving. African governments and the global health community spent  over US$3.6 billion  to end the West African epidemic and hundreds of millions of dollars more are now being directed to the current epidemic in DRC.

Although DRC is a member of the  UHC2030  Partnership, the government must show enough political will to take UHC to impoverished rural communities.

The first known case of the 2014 Ebola outbreak was a child in a poor, remote village in Guinea. If this infected child had had access to a clinic or hospital, medical personnel could have taken a laboratory sample,  identified the disease and initiated treatment. They also could have reduced Ebola’s spread by identifying contacts of the boy and providing continuous information on good basic health practices, such as hand washing and hygiene.

This is how things work in countries with UHC – including the United Kingdom (UK), Rwanda, Thailand, Japan and China.

In the UK in 2015, UHC enabled medical professionals to quickly identify a cluster of tuberculosis  within immigrant communities, treat those infected and prevent its spread.

Rwanda is one of the few African countries with UHC. Today, more than 97 percent of infacns in Rwanda are vaccinated against infectious diseases such as measles, polio and rubella, keeping cases close to zero.

Achieving UHC may seem like a Herculean task, but experience in countries as diverse as Rwanda and the United Kingdom show that it works. And, in addition to preventing and containing dangerous outbreaks, UHC could help keep them from becoming global pandemics. Today, an undetected pathogen can travel from a remote village to major cities across the world in less than a day.

Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, recently said, “Universal Health Coverage and global health security are two sides of the same coin.”

The DRC has declared its intention to put in place UHC. Egypt and a growing number of other countries have done the same. To make good on those intentions, countries and their global partners must identify appropriate financing mechanisms that would provide the safety nets needed to strengthen health systems and prevent the emergence and spread of infectious diseases.

Dr. Ifeanyi Nsofor is Director of Policy & Advocacy for Nigeria Health Watch, CEO of EpiAFRIC and a 2018 Aspen Institute New Voices Fellow.

The original article was first published in AllAfrica.

Opinion: Only 1 percent of Nigerians have health insurance. Here’s how to change that.

Opinion: Only 1 percent of Nigerians have health insurance. Here’s how to change that.

In 2009, our first daughter appeared healthy at birth, lively, and unspeakably cute. However, just four weeks later, her health was failing. She could not nurse and was rapidly losing weight. She cried inconsolably. An echocardiogram revealed the cause. She had congenital heart defects and needed open heart surgery, immediately. But this was not an option in Nigeria. And although my wife and I were both employed — and I worked as a medical doctor for an international nonprofit — we did not have the savings to pay for our daughter’s surgery in India. We suddenly faced both a health crisis and a financial disaster. Read more here.

Millions of Africans face such catastrophic health emergencies on a daily basis. Usually, however, the cause is preventable or at least easily treatable, if people have the money and the access to health care. But many never get the help they need. As a result, 145 women of childbearing age and 2,300 children under 5 years of age die daily in Nigeria. Women die in childbirth, children die of malnutrition, malaria, diarrhea, and pneumonia.

International funders spend billions on improving health care in Africa. But only through universal health coverage programs can the continent lock in progress. In Nigeria, Africa’s most populous country, the government and its partners should be leading the way by setting up a system to protect people against out-of-pocket payments that can represent a one-way ticket to poverty.

My wife and I were lucky. Our employers provided loans, and at reasonable terms, to cover the cost of our travel to India and our daughter’s surgery. But for most Nigerians, a health crisis that does not kill them pushes them more deeply into poverty. Today, nearly 72 percent of Nigerians’ total health expenditures are paid for out of pocket, forcing people to choose between their health, housing, education, and even food for their children. With 70 percent of the population already living in absolute poverty, Nigeria can ill afford to maintain this status

The government acknowledged this 12 years ago, when it established the National Health Insurance Scheme to provide health care to all Nigerians through various prepayment systems. But today, only 1 percent of Nigerians have health insurance.

Several factors are responsible for this: Leadership of the NHIS has been unstable; demand is low as few Nigerians know that national health insurance is available; and health insurance companies sometimes fail to remit NHIS funds to hospitals in a timely manner.

Universal health coverage, which entails providing effective access — including financial risk protection — to at least essential health care, is key to achieving the world’s Sustainable Development Goals. Spurred by these goals, momentum towards UHC is growing.

It takes political will for countries to implement UHC. And several African countries, including Botswana, Rwanda, and Ghana are demonstrating that will and finding innovative ways to fund UHC.

Ghana charges informal sector subscribers small premiums that average just $6.1 per year. In addition, it has implemented a value added tax, made National Health Insurance Fund investments and mandated social security deductions to individual’s income. Through these combined sources, the government of Ghana currently provides health insurance for about 40 percent of its population.

Nigeria, with a population of 186 million, is a much bigger deal. With the majority of Nigerians working in the informal sector, taxation has not been a realistic option for public financing of health. Therefore, Nigeria has required that one percent of the government’s total revenue and all donor funds earmarked for health care delivery be dedicated to a Basic Healthcare Provision Fund, which in turn finances the NHIS, the National Primary Health Care Development Agency, and emergency health care. This core funding is then supplemented by additional prepayment plans, all at a fraction of the cost of out-of-pocket expenditures paid by Nigerians.

Of course, the NHIS cannot pay for all health care expenses. But it should make basic health services much more affordable for the majority of Nigerians, especially the poorest. A functional, fully funded NHIS, combined with other prepayment plans, such as health insurance, would save countless lives as people receive the care they need, and prevent financial crises.

How do we ensure that no Nigerian family suffers the kind of catastrophic health expenditure that risked driving my family into poverty? To be sure, there are major challenges ahead in implementing UHC. But after 12 years of inaction, it is time to recommit to the principle of health for all. Recently, the Bill & Melinda Gates Foundation and the World Bank partnered with the Nigerian Federal Ministry of Health for a phased implementation of the Basic Healthcare Provision Fund in three Nigerian states. This implementation is projected to provide a basic package of health services to 8 million beneficiaries in rural communities in Abia, Niger, and Osun States.

Other international partners should contribute to this phased implementation, which could ultimately lead to UHC for all Nigerians.

Over the years, the development community has done much to improve the health in Nigeria. However, projects that insist on a siloed approach to treating specific health problems will never get to the root causes of continent-wide problems, including high rates of maternal and child mortality. The global push for universal health coverage can help Nigeria to turn the corner. And if Nigeria can help to show the way, real progress on African health will follow.

Ifeanyi Nsofor is director of policy and advocacy for Nigeria Health Watch, CEO of EpiAFRIC, and a 2018 Aspen Institute New Voices Fellow.

The original article was first published in Devex.

How tech can help win the fight against neglected tropical diseases

How tech can help win the fight against neglected tropical diseases

Fabiano grew up close to a fast-flowing river that irrigates the land in Uganda’s Nebbi District. Over the years as he farmed, he was repeatedly bitten by black flies that breed along the river banks. The bites caused constant itching. His skin thickened and discoloured until it resembled a leopard’s. But far worse, Fabiano lost his sight. Because of this, his first son dropped out of school to become his father’s guide.

Fabiano suffers from river blindness, or onchocerciasis, one of twenty Neglected Tropical Diseases (NTDs) that affect about 1.5 billion of the world’s poorest. That’s more than one-sixth of the global population. Caused by a variety of bacterial, parasitic, viral and fungal infections, these diseases can lead to blindness, disfigurement, malnutrition, growth failure and cognitive impairment.

NTDs are hugely serious, but many are preventable, treatable and can even be eliminated. Last month, for instance, Nigerian health officials and the Carter Centre announced that river blindness was no longer a threatin two states and that two million people could now stop taking ivermectin, the drug given annually to treat the disease. This success was hard won: it followed almost 30 years of laborious mapping of high risk areas and decades of using community volunteers for mass drug distribution. Beyond these two states, however, about 115 million Africans, including 50 million Nigerians, remain at risk from the disease.

Turbo boosting progress

Many of those vulnerable to NTDs live in poor, hard to reach areas. This exacerbates the agonisingly slow pace of progress in the control and elimination of these diseases. But it is now time to pick up the pace. And today, we have access to digital tools that can turbo boost progress. Through applying digital technologies like mobile phones, drones, and satellite data, we can overcome obstacles such as distance, shortage of health workers, lack of health infrastructure, and poor road systems.

In Africa, data show that more people have access to mobile phone service than piped water. These devices could be used to educate the public and community health workers about disease risks, prevention and treatment. This could be done through SMS or Interactive Voice Response systems for less literate populations. Big data, drones and satellite technology could also be deployed to educate the public; train community health workers; deliver medicines; develop health strategies; and map diseases.

In fact, there are already several examples of technology being used to improve health outcomes in resource-poor settings.

In Uganda, for example, health workers use the mobile system mTRAC to ensure crucial medicines remain stocked across the country. mTRAC enables health workers to send reports by SMS, including real-time data to map inventories. When stocks are known, rural people can avoid travelling long distances to health facilities only to find that drugs are unavailable.

In Brazil, Facebook partnered with UNICEF at the height of the Zika outbreak. The social media site shared anonymous user data on posts about the virus, which showed that 58% were by men. Equipped with this information, UNICEF designed a programme specifically targeted at engaging men as allies in the fight. This underscored the potential value of Big Data combined with human-centred design.

The Global Trachoma Mapping Project, a UK-funded initiative implemented in 29 countries, also reveals promise. The programme uses android technology to collect data from 2.6 million people. This information is then used to pinpoint regions with a high risk of trachoma, allowing partners to target the delivery of the SAFE strategy (Surgery, Antibiotics, Face washing and Environmental improvements) for trachoma control.

In Rwandadrones are now being used to transport blood to frontline health facilities. This technology be further utilised. Prevention of NTDs often involves community-wide drug distribution, for instance, but the safe movement of the medicines from cold storage to the ground level often presents major difficulties. Drones equipped with pouches could transport these drugs, avoiding the bottlenecks of bad roads, potential theft and long distances.

Coordinating and financing the fight against NTDs

The deployment of digital technologies will require funding of course. But in the long-run, these investments will save costs as they will accelerate the elimination of NTDs. In some cases, existing funds can be re-allocated. For example, drone technology could be funded from the same purse currently used for the road transport of drugs. In other cases, governments, private companies and donors should allocate the necessary funds.

In coming up smart solutions, partnerships between the health and technology communities will also be essential. Homegrown collaboration such as the “Health Meets Tech” hackathon planned in Abuja, Nigeria, provide key opportunities to generate creative solutions in real time.

If this all comes together the day that the bite of a black fly is no more than a nuisance will arrive much sooner, and people like Fabiano will be able to avoid lifetimes of pain and disability.

Ifeanyi Nsofor is Director of Policy & Advocacy for Nigeria Health Watch, CEO of EpiAFRIC, and a 2018 Aspen Institute New Voices Fellow.

The original article was first published in African Arguments.

Nigeria: Making Sense of a Young Doctor’s Death

Nigeria: Making Sense of a Young Doctor’s Death

Ahmed Victor Idowuwas a young medical doctor with a passion to reform health care in Nigeria.  A recent graduate of the University of Nigeria, in January 2018 he was at the start of  his in-hospital clinical training when he examined a seven-month old baby with an abnormally high fever. He was the only doctor on duty. It was his last duty. The baby had Lassa fever.  Less than a month later, Dr. Idowu died of the Ebola-like virus that in its most severe form causes multi-organ failure and uncontrolled bleeding from the nose, mouth, and gut.

His death was one of the first in Nigeria’s latest outbreak of Lassa fever, which now stands at 423 confirmed cases and 106 deaths. It was the worst Lassa Fever outbreak ever reported in Nigeria, with more cases in just two months than the entire previous year, and an exceptionally high fatality rate of 25 percent. Although the Nigerian minister of health recently declared the Lassa fever outbreak over, the virus remains an ever-present danger, as the conditions that breed it have not changed.

The vast majority of transmission is through rats, millions of which proliferate in parts of West Africa where clean water, toilets and sanitary sewage systems are lacking.  These conditions must change if we are to stop annual outbreaks of this potentially fatal disease.

Lassa Fever is endemic across West Africa. It currently causes up to 500,000 cases and 5,000 deaths yearly across West Africa, yet it has been a neglected disease since it was identified in 1969. Similarly, although the Ebola virus was identified in 1976, not until the widespread 2014 outbreak, when cases began appearing overseas, did the scientific and medical communities mobilize the muscle needed to rapidly develop tools for prevention, diagnosis and treatment—work that is still underway.

We cannot afford to continue the same mistake with Lassa fever.  With the worst of this outbreak behind us, the danger of complacency is high.

We know the animal host of Lassa fever, how it is transmitted, and how to stop it. It is time for African leaders and their global partners to treat the improvement of Water, Sanitation and Hygiene (WASH) as a priority, and to launch a massive behavior communications campaign to ensure that every West African knows the steps they must take to prevent this disease.

 In Nigeria alone, 37 percent of the population has no access to safe drinking water; 59 percent lack access to good waste disposal systems; and 28 percent still defecate in the open. In densely populated areas close to open sewage drainage, rats run amuck in households, eating stored grain and defecating on families’ food supplies and eating utensils.  Using those utensils and eating the contaminated foods is believed to be a primary cause of infection.

Therefore, risk communication is strategic to halting Lassa fever. Even with the paucity of health workers across West Africa, community health volunteers who are trained to provide health education and refer cases to higher levels of care have been shown to be very effective. This was demonstrated in Ethiopia, where 38,000 community health workers greatly increased child survival rates, and a core service was providing advice on water and sanitation.

African governments must also develop extensive waste management systems that prioritize solid waste sorting into recyclable and non-recyclable garbage. The non-recyclable is brought out for collection close to the time of waste collection to discourage rodents. Sewage should be hygienically managed and public toilets provided. Provision of clean water should be a priority. It is not possible to maintain good hygiene without access to clean water.

Risk communication, improved access to clean water and to safe sewage treatment are the key, but not the only measures needed. In addition, an international Dialogue hosted by the Nigeria Centre for Disease Control (NCDC) in March identified the development of rapid diagnostic tests (RDTs), real-time gene sequencing and the protection of health workers as crucial measures for preventing or controlling outbreaks.

Lassa fever cannot be eliminated without funding. To date, the World Health Organization’s Contingency Fund for Emergencies to Support Lassa Fever Preparedness and Response Capacities has released US$900,000 to address the outbreak.  But little of this goes to WASH.

The African Union recently established the Africa Centres for Disease Control and Prevention (Africa CDC) to monitor and respond to public health threats across the continent. The Africa CDC should now support the NCDC and other national public health institutes in their efforts to eliminate Lassa fever.

African leaders passively accept an annual outbreak of Lassa fever, with its preventable deaths of infants and adults alike. This must change.  When the 360 million people in West Africa know how to prevent this disease in their homes, and have access to clean water and to sanitary waste disposal, Lassa fever can finally be eliminated.

Dr. Ifeanyi Nsofor is Director of Policy & Advocacy for Nigeria Health Watch, CEO of EpiAFRIC and a 2018 Aspen Institute New Voices Fellow.

The original article was first published in AllAfrica.

Nigeria: Universal Access to Education is Social Justice

Nigeria: Universal Access to Education is Social Justice

Nelson Mandela famously said, “Education is the most powerful weapon which you can use to change the world.” Unfortunately, in many countries, including my own, too many children are still being denied an education. According to the latest statistics, Nigeria has 10.5 million children out of school, the highest number in the world. Most of those children come from the country’s poorest and most disadvantaged communities, and 60 percent of those children are in northern Nigeria.

I grew up in poverty, within a disadvantaged community much like the ones where Nigeria’s out-of-school children live. Yet my story is a testament to how education can improve one’s station in life – it very literally lifted me out of poverty.

Although I am originally from the southeastern part of Nigeria, I grew up in Kano State, in the northwest. My father was a junior police officer, while my mother was a petty banana trader. Neither one of them ever studied beyond primary school education. To pay my way through school, I had to support my mother by hawking bananas every day after school and during public holidays. Tray-loads of bananas can be quite heavy for a 10-year-old child. I remember days of walking long distances to sell bananas, and at one point I thought I would go bald in my later years due to the mark the heavy tray left on the top of my head. Some days, when I was unable to complete sales, I was reminded that my family needed all the money it could get to send me to school—I had to keep pushing.

Despite the challenges, I was lucky to have a mother who believed, like Nelson Mandela, in the power of education. Even if that meant hawking enough bananas to send me to university 900 kilometers away from home. Through hard work and some good fortune, I eventually graduated as a medical doctor in 1998. Those early years practicing as a doctor among disadvantaged communities were an eye-opener. Every day, people would present themselves with diseases that could have easily been prevented, if only they had been armed with the right information.

While working with Nigeria’s National Programme on Immunization, I heard about the Ford Foundation’s International Fellowship Program. At the time, I had never come across the term “social justice.” Yet I realized it’s what I had been doing: ensuring that the rights of the most vulnerable members of society are respected, and that programs – be they in health, water and sanitation, or education – take their needs and aspirations as a starting point.

Through the Fellowship, I pursued a master’s degree in community health at the Liverpool School of Tropical Medicine, in the United Kingdom. Beyond giving me access to a quality education, the Fellowship also paid for me to attend short courses at Oxford University, and broadened my networks. Once back in Nigeria, I even became a mentor to postgraduate students from the Liverpool School who came to Nigeria to conduct their research projects – just as I did mine in Zambia.

Everything rises and falls on education, and we are greatly damaging our continent’s future by not educating our children. We are also failing to help them become tomorrow’s leaders – leaders who would be best placed to advocate for the needs of their communities and come up with solutions to their problems.

In my current role, I lead efforts to ensure that all levels of government in Nigeria implement Universal Health Coverage so that that catastrophic health expenditures do not push people into poverty. An easy way for government to achieve this is providing health insurance for every Nigerian. Because of the education I received, I now find myself able to speak to local, regional and national authorities on behalf of marginalized communities, making their voices heard. Perhaps more importantly, I work directly with communities to educate them about health, and empower them to hold their elected representatives accountable.

Unfortunately, most people in Nigeria are not as lucky as I was. In 2015, around two thirds of students who sat for the country’s national entrance exam could not find a spot at a Nigerian university. Those who choose to study abroad often rely on scholarships, but those have come under threat in recent years following the country’s financial crisis.

It’s a well-known fact that education brings about many benefits, including huge potential impacts on a child’s health. Evidence shows, for example, that when girls are educated, they make better decisions regarding their health and wellbeing, and eventually that of their own children. Education also increases people’s earning capacity and gives them a voice to demand just and fair policies.

While I was fortunate to make it to medical school and later benefit from support from the Ford Foundation, as a country we cannot keep waiting for international donors to solve our social problems. As a first step, governments at all levels in Nigeria must provide free access to education for those 10.5 million out-of-school children.

Beyond that, we need to tackle our higher education woes, something that the country’s numerous high-net worth individuals can support. These individuals have an opportunity to foster the leaders of tomorrow by taking a leaf from the IFP quest to improve opportunities for education for marginalized communities, and start their own initiatives. Ultimately, we need to equip our nation’s most vulnerable communities with the right education so that they can go on to contribute to our nation’s health and prosperity.

Ifeanyi Nsofor is the Director of Policy and Advocacy at Nigeria Health Watch. He received support from the Ford Foundation’s International Fellowship Program to complete a master’s degree in community health from the Liverpool School of Tropical Medicine.

The original article was first published in AllAfrica.