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Volume 24, No 2, 2010, 87 – 153 |
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Editorial |
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| Bridging the divide: Linking training to services. Damen Haile Mariam |
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| Original articles | ||
| Assessing communication on sexual and reproductive health issues among high school students with their parents, Bullen Woreda, Benishangul Gumuz Region, North West Ethiopia. Desalegn Gebre Yesus, and Mesganaw Fantahun. | ||
| Applicability of the theory of planned behavior in predicting intended use of Voluntary HIV Counseling and Testing services among teachers of Harari Region, Ethiopia. Shemsedin Omer, and Jemal Haidar | ||
| Community based assessment on household management of waste and hygiene practices in Kersa Woreda, Eastern Ethiopia. Bizatu Mengistie, and Negga Baraki | ||
| Assessment of the impact of latrine utilization on diarrhoeal diseases in the rural community of Hulet Ejju Enessie Woreda, East Gojjam Zone, Amhara Region. Andualem Anteneh, and Abera Kumie | ||
| Healthcare waste generation and its management system: the case of health centers in West Gojjam Zone, Amhara Region, Ethiopia. Muluken Azage, and Abera Kumie | ||
| The status of rabies in Ethiopia: A retrospective record review. Asefa Deressa, Abraham Ali, Mekoro Beyene, Bethelehem Newaye Selassie, Eshetu Yimer and Kedir Hussen | ||
| Byssinosis and other respiratory symptoms among factory workers in Akaki textile factory, Ethiopia. Kassahun Alemu, Abera Kumie, Gail Davey | ||
| Collective radiation dose from diagnostic x-ray examination in nine public hospitals in Addis Ababa, Ethiopia. Daniel Admassie, Seife Teferi and Kalkidan Hailegenaw | ||
| Bibliography on HIV/AIDS | ||
| Hypertension, obesity and central obesity in diabetics and non diabetics in Southern Ethiopia. Araya Giday, Mistire Wolde and Dawit Yihdego | ||
| Comparison of formol-acetone concentration method with that of the direct iodine preparation and formol-ether concentration methods for examination of stool parasites. Feleke Moges, Yeshambel Belyhun, Moges Tiruneh, Yenew Kebede, Andargachew Mulu, Afework Kassu and Kahsay Huruy | ||
| Book review | ||
| Water Resources Management in Ethiopia: Implications for the Nile Basin. Edited by: Helmut Kloos and Worku Legesse. Reviewed by: Abera Kumie | ||
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ISSN 1021-6790
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Grammar and Glamour
Although I do some writing, I often find it difficult to write good papers. English is not my native language, and at school, grammar was not my favourite subject.
But, everyone can benefit from improved writing skills at work, at home, online, you name it.
I often use Strunk and White’s “Elements of Style.” But now another book is my favourite: “The Glamour of Grammar,” by Roy Peter Clark, which a book review in The New York Times says “is very much a manual for the 21st century”.
I recently read this fascinating book. To be honest, this is the only grammar book I have read from beginning to end, and I will use it to improve my language. I learned that for the good writer, no decision is too small, including whether to use “a” or “the”.
I did not associate the word grammar with glamour. The author explains: “The bridge between the words glamour and grammar is magic. According to the Oxford English Dictionary, glamour evolved from grammar through an ancient association between learning and enchantment. There was a time when grammar described not just language knowledge, but all forms of learning, ..”
The book is not only about grammar: it is about improving writing. Each chapter ends with “keepsakes” (reminders), where the author summarises important points and keeps things informal enough and thus avoids sounding like a textbook.
Surgeons and civic-professionalism
Surgery is often the only solution to prevent disabilities and death from conditions resulting from pregnancy related complications, surgical conditions (example acute abdomen), infections, traffic accidents, falls, burns, disasters, domestic violence, and congenital defects.
Until recently, surgery was neglected as a developing country public health issue. Health officials, especially in the World Health organization and in major international Non-Governmental Organizations often viewed it as expensive and unnecessary tertiary care needing advanced equipment and expertise.
Recently, surgery is beginning to be seen as an integral part of primary health care. Often it is a preventive and a cost-effective way of dealing with many health challenges in poor countries. WHO now recommends that basic surgical services should be available in district hospitals, while more specialised surgery is performed at tertiary level hospitals.
A recent article in The Lancet (Funk, Weiser et al. 2010) show there are less than 1 surgical theatre per 100.000 people in Africa (14 times less than in Europe). In addition, there are too few surgeons, and 95% of these surgeons work in urban areas.
Addressing the inequities in access to essential surgery, an Editorial in the Lancet also underlined the need for improved professionalism and leadership among surgeons. The civic-professionalism should be addressed among surgeons in speaking for equity at local, national and global levels. (Editor 2010)
Death and disability in the most vulnerable groups (namely, women and children) are easily prevented or corrected by surgery. Most essential and surgical interventions can be delivered at the first referral level health institution (rural or district hospital, health centre, primary healthcare institutions) provided the health care staff know few basic skills and their institution have some basic equipment.
Priorities include work to:
• strengthen capacity to deliver effective emergency surgical care at the first referral level facility, and thus working towards achieving the WHO Millennium Development Goal 5 (reducing maternal deaths).
• improve the quality of care through safe and proper use of emergency and essential surgical procedures
• strengthen existing training and education programmes in safety of essential procedures
There are very few surgeons in South Ethiopia. We therefore train Non-Clinical Physicians to do essential obstetrics and surgery. Currently, this programme includes twelve institutions covering about 3 million people.
Editor (2010). “What is the point of surgery?” Lancet 376(9746): 1025.
Funk, L., Weiser, T., Berry, W., Lipsitz, S., Merry, A., Enright, A., Wilson, I., Dziekan, G., & Gawande, A. (2010). Global operating theatre distribution and pulse oximetry supply: an estimation from reported data The Lancet, 376 (9746), 1055-1061 DOI: 10.1016/S0140-6736(10)60392-3
Missing AIDS Patients
It is important for HIV infected patients to take their drugs regularly. Interruptions in treatment lead to viral strains that are resistant to the cheapest medications, and to higher rates of illness and death. Unfortunately, many AIDS patients do not come for their antiretroviral medications. Such patients are labelled as “lost to follow-up.”
During the early years of antiretroviral treatment (ART) drug distribution in Africa, researchers reported high rates of adherence to treatment, often as high as in Europe or the United States. At the same time, studies showed higher early mortality rates among patients treated with antiretroviral drugs in settings with limited resources. A reason for the high death rates was late presentation of patients to care.
In a recent review of 2191 adult HIV patients in south Ethiopia, we show that patients now start to present at earlier stages of their illness, and death has decreased among adult HIV patients. Early treatment start contributed to improved survival (Mulissa, Jerene and Lindtjørn, 2010).
Unfortunately, 25 per cent were lost before that started treatment. This means they were diagnosed, but did not return for treatment, and this have increased during the recent years. We also found that 15% per cent of those who start treatment were lost to follow up. 40% of the latter group had died, and 20% had started treatment in another institution.
Some ART programmes in Africa are experimenting with different programmes to reduce loss to follow-up. Some organizations offer a two- or three-month supply of medication for each clinic visit, others deliver drugs to patients’ homes, and some have tried to refund patients for transport costs. None of these efforts have been evaluated.
Mulissa, Z., Jerene, D., & Lindtjørn, B. (2010). Patients Present Earlier and Survival Has Improved, but Pre-ART Attrition Is High in a Six-Year HIV Cohort Data from Ethiopia PLoS ONE, 5 (10) DOI: 10.1371/journal.pone.0013268
EMAPS 2011 Annual Meeting
The Ethiopian Malaria Prediction System (EMAPS) Annual Meeting will be on Monday and Tuesday January 10 and 11 at Ghion Hotel in Addis Ababa.
We plan the meeting as an open scientific meeting, and malaria interested scientists in Ethiopia are invited to take part in the meeting.
We will have one or two lectures at the start of the workshop. Our main emphasis is on forecasting malaria epidemics, and we aim to build our scientific meeting around our modelling efforts.
We shall discuss this in thematic areas such as: mosquito dynamics and behaviour, human host infection (highland, and lowland areas), environmental (hydrology and climate/meteorology), and modelling (captures the whole or part of the information collected so far).
Active case finding in tuberculosis
Even if 36 million patients with tuberculosis were successfully treated, and up to 6 million lives were saved during the past 15 years, tuberculosis remains a major public health problem. More than 9 million cases occur every year.
Unfortunately, only a little more that half of the expected cases are identified yearly and receive proper care. We therefore need novel measures to diagnose, treat, and thus stop transmission of tuberculosis.
Many have previously questioned the role of active case finding in reducing tuberculosis prevalence. Recently, several active case-finding strategies for tuberculosis were tested and proved to be effective, both in urban (Corbett, Bandason et al. 2010) and rural settings (Datiko and Lindtjørn 2009). The Lancet study (Corbett, Bandason et al. 2010) also documented the effect on the prevalence of culture-positive tuberculosis. The study from Ethiopia also showed that active case finding is a cost-effective strategy (Datiko and Lindtjørn 2010).
These studies highlight active case-finding in tuberculosis control efforts, especially in settings where HIV is prevalent and in weak health systems.
Some of the research priorities for countries with weak health systems should include:
- Evaluate tools for effective active case-finding so it reduces tuberculosis prevalence. To do this we should also set up good records on tuberculosis prevalence, and thus be able to document a future decline in tuberculosis prevalence.
- We need to develop different models for active case finding in communities. By this, I mean practical tools on how to do this in a local community. We are starting a new research in Ethiopia to develop “tuberculosis suspect registries” in the communities as a tool to identify patients with tuberculosis.
- In addition, we urgently need fast, accurate, and simple diagnostic test.
And, scaling up active case-finding outside health institutions needs to be paired with increased scientific interest, research investment, and political commitment for high-quality basic and operational research.
Corbett, E., Bandason, T., Duong, T., Dauya, E., Makamure, B., Churchyard, G., Williams, B., Munyati, S., Butterworth, A., & Mason, P. (2010). Comparison of two active case-finding strategies for community-based diagnosis of symptomatic smear-positive tuberculosis and control of infectious tuberculosis in Harare, Zimbabwe (DETECTB): a cluster-randomised trial The Lancet, 376 (9748), 1244-1253 DOI: 10.1016/S0140-6736(10)61425-0
Datiko DG, Lindtjorn B (2009) Health extension workers improve tuberculosis case detection and treatment success in southern Ethiopia: a community randomized trial. PLoS One 4: e5443.
Datiko DG, Lindtjorn B (2010) Cost and cost-effectiveness of smear-positive tuberculosis treatment by Health Extension Workers in Southern Ethiopia: a community randomized trial. PLoS One 5: e9158.
Official statistics underestimate malaria deaths in India
A recent Lancet study (Dhingra, Jha et al. 2010), show there are 13 times more malaria deaths in India than the World Health Organisation (WHO) estimates. The authors conclude that malaria kills more than 200,000 deaths each year in India. And, the findings suggest that malaria kills not just children, but also adults.
In this study, fieldworkers asked families to describe how their relative died. Two doctors then reviewed each description, and decided if the death cause was malaria. This method is called verbal autopsy.
The WHO disputes these figures, mainly because of the doubt of using verbal autopsies in diagnosing malaria. However, the same organisation (WHO) often recommends such studies to measure mortality rates in communities when vital registration is not available.
This research is important as it raises doubts over the total number of malaria deaths worldwide, including Africa. The findings are consistent with the spatial and temporal epidemiology of malaria in India (Hay, Okiro et al. 2010), and suggest the WHO has underestimated the clinical incidence of malaria in India by a similar order of magnitude.
However, In a recent commentary in Nature, Butler (Butler 2010) discusses that Verbal autopsy is increasingly being questioned by statisticians. On a population level, the aim of verbal autopsy is not to make clinical diagnoses of individual cases, but to estimate the distribution of causes of deaths (cause-specific mortality fractions (CSMFs)). Such a measure is better for setting health-system and research priorities, and to overseeing the effectiveness of disease-control measures.
Dhingra, N., Jha, P., Sharma, V., Cohen, A., Jotkar, R., Rodriguez, P., Bassani, D., Suraweera, W., Laxminarayan, R., & Peto, R. (2010). Adult and child malaria mortality in India: a nationally representative mortality survey The Lancet DOI: 10.1016/S0140-6736(10)60831-8
Butler, D. (2010). Verbal autopsy methods questioned Nature, 467 (7319), 1015-1015 DOI: 10.1038/4671015a
Hay, S., Okiro, E., Gething, P., Patil, A., Tatem, A., Guerra, C., & Snow, R. (2010). Estimating the Global Clinical Burden of Plasmodium falciparum Malaria in 2007 PLoS Medicine, 7 (6) DOI: 10.1371/journal.pmed.1000290
Achieving MDGs?
The United Nations recently discussed the achievements so far in achieving the Millennium Development Goals. The goals aim to:
- Eradicate extreme poverty and hunger
- Achieve universal primary education
- Promote gender equality and empower women
- Reduce child mortality
- Improve maternal health
- Combat HIV/Aids, malaria and other diseases
- Ensure environmental sustainability
- Develop a Global Partnership for Development
The Prime Minister of Norway, Jens Stoltenberg and the Gordon Brown, former PM of Great Britain, underline that governments of poorer nations have to put resources into education and health, and not into corruption.
As I have outlined previously, corruption is widespread at health institutions. Fighting corruption is necessary because corruption reduces the resources available for health. Corruption also lowers the quality, equity and effectiveness of health care services, and it decreases the volume and increases the cost of provided services. Corruption also discourages people to use and pay for health services.
It is encouraging that world leaders talk about broadening the tax base, and identify fighting corruption as a means of achieving the MDGs. The leading donors should encourage governments to put in place mechanisms at each institution to reduce corruption. This should include such basic functions and proper accounting systems and mechanisms for independent financial audits.
Open Access Journals
About 10 years ago, some scientists started an ‘open access’ campaign for free journals funded by author fees. A reason to start the open access journals was to make scientific publications available for researchers in developing countries. Can we after 10 years say that researchers in the poorer countries have benefited from this exercise?
The two most important publishers are Public Library of Science (with six journals) and BioMedCentral (with 206 journals). By various measures about 10% of all biomedical journals are now open access. PLoSONE expects to publish about 7500 papers this year, making it the world’s largest journal in terms of volume.
A review in 2009 shows an 8% citation advantage for open-access articles, although the rate was higher in developing countries (Evand and Reimer, 2009).From personal experience I have learned that Ethiopian researchers try to publish in open access journals. This is a natural development because they are exempted from paying the processing fees.
Another benefit for researchers in developing countries is that many of the open access journals have a good citation index, showing that research papers are widely read and cited.
However, there is also a weakness in the open access publishing for developing countries. Unfortunately, the scientific literature the researchers read and cite is often limited to articles found in open access journals. This may result in a selective reading of researchers and students.
So researchers in the poor countries need to have better access to read journals. Unfortunately, initiatives as HINARI are often limited to a few individuals and to libraries.
Evans, J., & Reimer, J. (2009). Open Access and Global Participation in Science Science, 323 (5917), 1025-1025 DOI: 10.1126/science.1154562
Is Ethiopia reaching the development millennium goals (MDG)?
Although Ethiopia has shown an impressive economic growth over the last seven years, one-third of its population remains poor. To achieve the MDG, an annual economic growth of 7 % is needed, and in the last years the growth has exceeded this critical figure.
A recent conference in Cape Town evaluated the performance of different countries, including Ethiopia, on achieving the MGD goals 1. The country is making some progress on indicators such as vaccination coverage and malaria control. Child mortality rates are declining, and HIV care is improving. Unfortunately, only 11% of the population have good access to emergency obstetric care, and the levels of stunting, an indicator of chronic malnutrition and poverty, is not declining. Tuberculosis case detection rates remain low.
One way to compare access to health services is to use the coverage index. The index uses some indicators for eight reproductive, maternal, newborn and child interventions. They include family planning, maternal and newborn health (at least one antenatal visit and skilled attendant at delivery), immunisations (measles, BCG and DPT3) and curative childcare (diarrhoea and pneumonia management: oral rehydration and continued feeding and care seeking for pneumonia). Unfortunately, there is still a 80% health coverage gap for most Ethiopians, and for the more wealthy part of the population, the coverage gap is still 60%, one of the worst in Africa.
Currently a new health sector plan is being approved. Although the details of this plan remains unknown to the public, the vision of the government is to transform Ethiopia to become a middle-income country in a few years after the end MDG 2015. The most concrete step that I have heard about is to improve access to essential health services by setting up primary hospitals to serve a population of 60 – 100.000 people . Each primary hospitals shall provide emergency surgical services focusing on Comprehensive Emergency Obstetric Care. Improved access and improved infrastructure would in theory enable the government to reduce maternal deaths.
Full report:
Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J, Bustreo F, Cavagnero E, Cometto G, Daelmans B, de Francisco A, Fogstad H, Gupta N, Laski L, Lawn J, Maliqi B, Mason E, Pitt C, Requejo J, Starrs A, Victora CG, & Wardlaw T (2010). Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child survival. Lancet, 375 (9730), 2032-44 PMID: 20569843