HEALTH

by Ben Taylor

Drug shortage
A serious shortage of drugs in public health facilities in November led to calls by some MPs for the parliamentary session to be cut short and for the money saved to be used to alleviate the problem. The crisis devel­oped after Medical Stores Department (MSD) stopped supplying public hospitals with drugs and other consumables, due to non-payment by the government. Sikika, a lobby group that advocates quality health services for Tanzanians, said that the government owes MSD TSh90 bil­lion, while CUF chairman Ibrahim Lipumba said that the actual amount was TSh120 billion. The crisis came in the wake of the suspension by the donor community of general budget support (see Energy Scandal Story).

Hospital ship for Lake Victoria

Jubilee Hope leaving the Clyde (Vine Trust)

Jubilee Hope leaving the Clyde (Vine Trust)


In October Princess Anne launched the medical ship Jubilee Hope on Lake Victoria. The 150-ton former Royal Navy tender has been converted to serve as a floating hospital. It arrived at Lake Victoria after six months at sea and 850km over land from Mombasa. The ship was fitted out on the Clyde by BAE Systems and has an operating theatre, two consulting areas, an eye surgery a full dental surgery and a laboratory.

The project, which com­memorates the Diamond Jubilee of Queen Elizabeth II, will offer medical care to a population of 400,000 in isolated communities on islands and around the shores of Lake Victoria. Geita Gold Mine, a subsidiary of Anglo Gold Ashanti Ltd, will refuel the ship until 2019 at a cost of $500,000 (TSh 825 million). “GGM is proud to participate in this noble initiative,” said managing director of GGM Michael Van Anen, “This is in keeping with our core value of leaving our host communities with sustainable futures.”

Willie McPherson, CEO of the charity Vine Trust which organised the project, said: “I’m delighted with the optimism and goodwill greeting the Jubilee Hope in Tanzania and the wide support amongst those concerned with primary health care in the island communities.”

HEALTH

by Ben Taylor

2012 census shows improvements in public health
The number of years the average Tanzanian can expect to live has risen to 61 years, up from 50 years in 1988 and 51 years in 2002, according to the latest release of data from the 2012 Census. The report also showed that similarly strong progress has been made in maternal and infant mortality rates. The maternal mortality rate has dropped from 578 per 100,000 live births in 2004/5 to 432 per 100,000 in 2012, and the infant mortality rate has declined from 115 per 1,000 live births in 1988 to 45 per 1,000 in 2012.

The fertility level declined from 6.5 in 1988 to 6.3 in 2002 and 5.2 in 2012. ‘It’s a positive trend accelerated by higher use of modern contraceptives and female education while the age at first marriage has been rising,’ commented Ms Albina Chuwa, director general of the National Bureau of Statistics.

The mean age for female first marriage rose from 21 in 2002 to 22 in 2012 while that of males remained steady at 26, according to the report. (The Citizen)

Dengue Fever Outbreak
There was widespread concern, particularly in Dar es Salaam, after an outbreak of Dengue Fever in May. Within a couple of weeks, the Ministry of Health announced that 400 cases had been reported, of which three patients had died.

There was a fear that popular awareness of malarial prevention and treatment could work against dengue control. Dengue is spread by a different species of mosquito, popular practice of self-diagnosis and treatment could create problems.

Worries rose briefly to panic, when a high profile doctor at Temeke Regional Hospital, Gilbert Buberwa, died. This prompted President Kikwete to take action, directing the Health and Finance Ministries to do whatever was necessary to bring the outbreak under control, and urging the public to take precautions.

By July, the rate of infections had dropped to such an extent that the National Institute for Medical Research could not find a single Dengue Fever patient in Dar hospitals.

HEALTH

by Ben Taylor

Teen pregnancy
East Africa ranks second globally after West Africa as the region with the highest number of women reporting a birth before the age of 18, according to a new report by the United Nations Population Fund (UNFPA). The report, Motherhood in Childhood: Facing the challenge of adolescent pregnancy, said Uganda leads the region in teenage pregnancies at 33% followed by Tanzania (28%) and Kenya (26%).

This is a big concern for policymakers given that the five East African Community countries are grappling with fast-rising populations that threaten to strain their limited economic resources. The high population growth rates are blamed on low usage of contraceptives.

A second recent report, Forced out, by the Centre for Reproductive Rights, indicated that over 55,000 female students in Tanzania have had to leave schools in the past decade because of pregnancy. Contraceptive use among adolescent girls remains minimal; only 10.7% of sexually active women aged 15-19 report using any family planning method.
(The East African)

Good progress on malaria
Tanzania leads Africa in the proportion of households owning Insecticide Treated Nets (ITN), according to the World Malaria Report, published by the World Health Organisation. Over 50% of Tanzanian households own enough nets for all household members, and 91% of households own at least one treated net. The report notes that Tanzania has also made good progress in the incidence of malaria, from nearly 13 million cases in 2009 to under three million in 2012, and from 16,776 deaths in 2009 to 7820 in 2012. (The Citizen)

HEALTH

by Ben Taylor

Tanzania meets child mortality target
A recent report from the United Nations estimates that the under-five mortality rate has dropped by two-thirds between 1990 and 2012 – from 166 to 54 deaths per 1000 live births. This puts Tanzania among a select few countries in sub-Saharan Africa to have met the Millennium Development Goal no. 4, along with Ethiopia, Malawi and Liberia.

Progress on related measures has also been good. On Infant mortality (deaths at under 12 months), the number of deaths per 100 live births has dropped from 101 in 1990 to 38 in 2012, and the neo-natal mortality rate (deaths in the first 28 days of life) has halved from 43 to 21 per 1000 live births in the same period.

Chart to measure baby foot length

Chart to measure baby foot length


An initiative reported by the BBC aims to help identify premature babies, since in rural Tanzania about one in every 30 premature babies will not survive beyond four weeks. “There’s this grey area when the baby is between around 2.4kg (5lbs 5oz) and 2.1kg (4lbs 10oz) when the baby is more vulnerable to infection and other issues,” says Dr Joanna Schellenberg of the London School of Hygiene and Tropical Medicine, “But when a baby is born at home, there is no way of weighing them”.

To help solve this problem, Schellenberg and her colleagues at the Ifakara Health Institute have implemented a strategy called Mtunze Mtoto Mchanga (“protect the newborn baby”). Based on research into baby foot lengths carried out in Lindi and Mtwara, the newborn baby’s foot is compared against a laminated card. If the foot is smaller than the small foot (67mm), the mother is advised to take the baby to hospital immediately. Babies with foot size in the medium range are advised to take extra precautions such as carrying the baby “skin-to-skin” so that the mother’s warmth is shared by the baby. The project relies on volunteers to measure the babies and help educate mothers, and WHO estimate that 75% of deaths in preterm infants can be prevented in this way – without the cost and emotional upset of intensive care.

Heart treatment centre
A new ultra-modern Cardiac Treatment and Training Centre has been opened at Muhimbili National Hospital in Dar es Salaam. The facility cost $20m to build, shared between the Tanzanian and Chinese governments.

The government has paid for 326 people to go for heart surgery abroad, at a minimum cost of $10,000 for each case. The new centre should be able to deal with the majority of such cases locally at much lower cost.

Improved malaria testing
The Ministry of Health and Social Welfare will make malaria Rapid Diagnostic Test (mRDT) equipment available in both government and private health facilities. The Minister said that the equipment gives faster and more reliable results than microscopic tests.

The scheme, which has been introduced by the Clinton Health Access Initiative and the National Malaria Control Programme, reduces the cost of the equipment from TSh 9,000 to TSh 1,100. (Citizen)

HEALTH

by Ben Taylor

HIV sector faces funding crisis
The Executive Chairperson of the Tanzania Commission for HIV/AIDS (TACAIDS), Dr Fatma Mrisho, warned that donor funding for the fight against HIV and AIDS was at risk. She said that the Canadian and Danish governments had informed her that from 2015, they would no longer provide financial support to the National Multi-Sectoral Strategic Framework. In addition, the US President’s Emergency Plan for AIDS Relief (PEPFAR) is also reducing funding. “We, as a nation, need to get prompt replacement for the funding, failure of which all the achievements made in the fight against HIV and Aids for more than 20 years will experience a heavy blow,” said Dr Mrisho. (Daily News)

Drop in new HIV infections among children
Tanzania recorded a decline in new HIV infections among children between 2009 and 2012, according to a new report by the UN on “The Global Plan towards elimination of new HIV infections among chil­dren”. Nevertheless, the Global Plan indicated that since only 53% of eligible pregnant women and 26% of eligible children are currently receiving antiretroviral therapy, the country should continue to focus on providing treatment. (East African)

Dengue fever outbreak
The Minister for Health and Social Welfare, Hussein Mwinyi, announced that several deaths from dengue fever had been reported at Muhimbili National Hospital in Dar es Salaam. Preventive measures, including sensitising the public about the deadly disease, are being taken. (East African)

Bacteria to be deployed against mosquito larvae
A $22 million biolarvicide plant is under construction in Kibaha, with the potential to provide a valuable new weapon in the battle against malaria, one of the country’s biggest killers. The project, a joint venture between the Tanzanian government and a Cuban state-owned firm, will produce a more eco-friendly alternative to synthetic larvacides. The biolarvicides contain toxins that specifically target mosquito larvae. Tanzania is spending about $240 million (a staggering 3.4 per cent of GDP) annually to treat malaria. This suggests that of the $11.37 being spent per person per year on health, $2.14 is spent on treating malaria and its complications. (East African)

DOCTORS STRIKE

A number of doctors have been involved for several months in an on/off strike in Tanzania demanding improvements in the health service in the country and in their remuneration. The media, in what may have been an exaggeration, wrote that the strike had ‘paralysed health sector operations in all major public hospitals.’ From the beginning the government has taken a hard line. It is believed to have sacked some doctors, brought in doctors from outside the country and firmly rejected the strikers’ demands.

There was considerable shock when Dr Steven Ulimboka, chairman of the Interim Doctors Committee and spokesperson for the doctors, was abducted, tortured and left for dead at the Pande forest in the northern precincts of Dar es Salaam. His injuries were so serious that he had to be moved to South Africa for six weeks to recover and did not return to Tanzania until August 12. He was reported in the media to have ‘failed to hold back tears’ when relatives, friends, activists and hundreds of other people welcomed him back at Dar Airport.

There is some mystery as to who kidnapped and tortured Dr Ulimboka. The Medical Association of Tanzania (MAT) Secretary General, Dr Rodrick Kabangila, said the Association was pleased with the recovery and return of one of their members. “His homecoming might also shed light on what actually happened and the persons who did what they did to him… we might know the truth eventually, regardless of the police reports on the arrest and charging of one man in connection with his tribulations.”

On July 7 religious leaders held prayers for Dr Ulimboka and asked President Kikwete to form an independent commission of inquiry to investigate the abduction and torture. They also called for the immediate resumption of negotiations between the government and striking doctors to end the standoff. The clerics urged the government to drop the case it had filed at the High Court against the doctors before talks could resume.

THE NEW ‘CHOO MEN’

Of the 3 million people living in Dar, around 13% discharge their effluent into a sewer, another 13% have a septic tank and 74% rely on pit latrines. A “good” latrine is permanent, clean and with a porcelain bowl within a walled and roofed area. Such latrines, which are available only to the better off, cost around US$350. Others are more basic and vary in depth from 1 – 3 metres. The median number of users per latrine is 7 adults, which suggests that there are around 300,000 pit latrines in Dar.

Because the pit is of a fixed volume, it will inevitably fill up and need emptying – which costs up to US$80. Formal ways of doing this include draining into a parallel pit – this option is usually cheaper, but not effective for sludge removal, emptying manually (using a bucket) or sucking out with a vacuum tanker – although in the unplanned areas there is rarely vehicular access to latrines. Officially the responsibility of the landlord, few landlords are interested in paying for pit emptying and the reality is that it is often left to the tenants. As many lack the funds, or have other more immediate priorities, many resort to “flooding out” during periods of heavy rain – when the contents are simply allowed to spill out into the general (often open) drainage. Apart from many pits being full, where the water table is high or where the soil is sandy and walls collapse, sewage seeps into, and pollutes, the groundwater.

Health Hazard
These unsanitary conditions are reflected in high levels of oral-faecal transmitted diarrhoea diseases. The 2004 Demographic Health Survey found that 7% of children under five in Dar es Salaam had experienced diarrhoea in the two weeks prior to data collection and the Ministry of Health report that 60-80% of hospital admissions are due to sanitation-related diseases. Temeke Municipality report that 97% of out-patients attending health centres were suffering from sanitation-related diseases. Between 1998 and 2005 close to 7000 cases of cholera have been reported in the city (MoH 2006). Thus sanitation in Dar es Salaam remains a primary public health concern.

The Costs
As is often the case, the poorest pay most for basic services. Whilst those on mains sewers pay TShs 300 per m³ for complete disposal of their sewage (having paid nothing for the construction of the sewer lines), those with septic tanks and pit latrines pay TShs 1,000 and TShs 1,700 per m³ respectively just for the cost of dumping into the lagoons. Add in the cost of emptying and transporting to the lagoon (excluding the cost of building the tank/latrine in the first place) and the cost increases to TShs 7,500 per m³ for a tank and TShs 70,000 per m³ for a latrine! It is not surprising that most people find an easier way to dispose of the contents of their latrines.

Emptying and Transporting
There have been a number of attempts to empty the latrines and transport the contents to the lagoons. There are two quite different elements – emptying/sucking out and transporting. Transporting long distances should be done in large volumes, but equipment needs to be small to be able to manoeuvre in the small spaces between the houses. Most dual-purpose equipment has failed – perhaps good at sucking out but too slow on the road. However, a new approach has emerged – which separates extraction from transport – and builds on the way in which solid (household) waste is disposed. It was developed by Steven Sugden of the London School of Hygiene and Tropical Medicine and Water Aid, working with officials in Temeke Municipal Council.

the Gulper Dar-es-Salaan

Operators on their way to service a pit latrine (photo by John Meadley)

The Gulper
The Gulper – developed by Steven and a dairy farmer in Yorkshire – is a simple but effective piece of hand powered equipment that sucks the top 800 mm of sludge out of the latrine into (enclosed) buckets, which are hand carried to a waiting cart.

In the early 2000s, a new franchise system for the collection of solid waste was introduced into Dar. The franchisees were originally large companies with trucks, which tended to focus on the planned areas where collection was easier. In the unplanned areas the work has been done increasingly by individuals using the ubiquitous hand carts – which can carry up to 300kg of solid waste and which take the waste to collection points, from where it is transported to the landfill sites which are now located outside the city. By adding a plastic tank the conventional push cart can be converted into a small tanker to transport the sludge to the treatment lagoons. As there is clearly a limit to how far someone can push a cart weighing 300kg, the possibility of building a number of transfer tanks is being investigated – which can hold the sludge for 2-3 days until there is enough to justify emptying by vacuum tanker.

These are still early days. The gulper works well and is likely to be replaced by a modified and more efficient one. With the combined cost of a Gulper and a modified pushcart being around US$500, the cost of starting a small business is reasonably affordable. Charging TShs 18,000 for removing 300 litres of sludge, a two-man team can make a reasonable living emptying two latrines per day. The main constraints are people’s willingness to pay and the distance to the lagoons. The cost of emptying could be subsidised through a voucher scheme – why should the poorest pay most for the disposal of their waste? – whilst discussions continue with the local authorities. It is possible that in the coming years an increasing number of latrines will be emptied by small operators who both make a living for themselves and create a healthier environment. Ironically, the capital cost of providing enough gulpers, carts and transfer tanks to remove 300 litres from 30% of the latrines in Dar each year is less than US$300,000 – too small to interest most international donors!
John Meadley

STEALTH VIRUS

NEW SCIENTIST (April 21) described how a farmer in Zanzibar, had a severe shock four years ago when he went to harvest his cassava (manioc). “The bushes looked healthy” he said, but when he dug up the tubers he found every last one had rotted away. “I had lost my entire crop. And we were hungry and I was desperate”.

What he didn’t know then was that his crop was the first known victim of a plague caused by a new and virulent strain of the ‘cassava brown streak virus’ that is now spreading across eastern and central Africa. Other pests and viruses that afflict cassava – notably the ‘cassava mosaic virus’, which has been advancing across East Africa since the late 1980s, leave visible marks on the foliage but always spare some of the crop.

Brown streak is a stealth virus. It has been known since 1935 when British scientists reported it in coastal Tanganyika but, until recently, it remained largely confined to Tanzania’s low-lying coastal plains. Now it has become much more virulent – apparently starting from this farm in Zanzibar. It is a threat to the whole of sub-Saharan Africa. According to the Institute for Tropical Agriculture’s branch in Dar es Salaam, cassava yield in Tanzania has fallen by between 50 and 80 per cent and during the past five years. The economic damage to farmers is conservatively estimated at more than $50 million a year.

The institute has cross-bred some of the local varieties in Zanzibar with other varieties that seem to tolerate the new virus. The first trials have been successful and some of the new varieties have now been released to farmers in Zanzibar so moving from trials to a fully operational project. Farmers in Zanzibar are clamouring for the new varieties especially a variety called Kiroba which is a favourite because of its sweet taste and smooth texture.
Thank you John Rollinson for sending this news – Editor

CIRCUMCISION THE SOLUTION ?

The UN has begun to advocate mass male circumcision in HIV/Aids stricken Southern African nations. Several recent medical studies have confirmed that circumcision cuts the risk of HIV infection among men by 50-60 per cent, and the findings have been backed by UNAIDS.

However, in Tanzania, the Government remained cautious. “We cannot rush into this idea. We want to conduct a thorough study on the suggestions and get clear evidence before incorporating the idea in our HIV/Aids policy framework” said Health and Social Welfare Minister, Prof. David Mwakyusa. He admitted that the prevalence rate in certain coast and central areas in Tanzania was low due to male circumcision. “I am talking to experts who are meeting in Arusha. I hope they will come up with sound suggestions and advise the government accordingly” – Guardian.

The government has assured the public that, Rift Valley Fever, which had been widespread for more than five months, is now under total control.

“A HEALTH TONIC FROM GOD”

This is how Sister Levina describes Moringa Oleifera, a medicinal tree being grown by the ‘Medical Missionaries of Mary’ at their training centre in the Maasai village of Ngaremtoni. Moringa is nutritionally rich, drought resistant and extremely fast-growing, and can be harvested as little as 5 months after being planted. Nutritionally, the plant is at its optimum when the leaves are dried into a powder, which can be added to food or drinks. Gram for gram, Moringa leaf powder contains 10 times the vitamin A content of carrots, 9 times the protein content of yoghurt, 17 times the calcium content of milk, and 25 times the iron content of spinach. Indeed, research in Senegal has found that using Moringa powder reduces levels of anaemia in pregnant women, improves birth weights and development in babies and produces better quality breastmilk. Continue reading