19 June 2000
Source: World Health Organization
‘Green hunger’ grips drought lands
A traveller in the North Omo zone, eight hours drive south-west from Addis Ababa, might look out of the window of the car and believe in this part of Ethiopia there is no drought, no starving children, even that the people are prospering. The arrival of sporadic rains in the past two months has covered much of the pastures with a patina of vivid green, and the hillsides and lowlands are sprouting young sweet corn plants, flowering sweet potatoes and fragile cereal grass.
But the green is a cruel deception. North OMO is in the grip of the ‘green hunger’ – a malnutrition paradoxically hidden by a cloak of vibrant growth.
Inside their thatched huts, over 50% of the people in this district’s most drought-stricken areas have nothing left in their pots and baskets. And they will continue to have nothing for three more long months until, weather permitting, the crops ripen.
Their dire situation is the result of three years of poor rainfall plus three consecutive pest-induced failures of the staple sweet potato crop which traditionally wards off the hunger gap between seasons. But the effect of these natural crises is also exacerbated by one of the highest population densities in Ethiopia which leaves most households with less than half a hectare from which to feed themselves.
"In other areas, you never see a house without a grain store, but here they have nothing now, just all the green stuff around them," says Dr Kelemu Desta, hospital medical director in Soddo, the area’s main town.
The woreda (district) council of Damot Weyde, one of the worst affected areas, estimates over 110,000 of the 179,000 population need food aid, while a nutrition survey, carried out by international NGO Concern together with local NGO Wontta, in mid-April puts global malnutrition of children under five at 26% - almost 10 times ‘normal’ rates.
The survey, carried out using standard WHO methodology in 30 randomised clusters, analysed 960 children by weight for height and Z-score. The team also assessed the children’s mothers nutritional status using upper arm measurement and found again over a quarter were malnourished.
The hunger is also having disease consequences, say researchers Mary Corbett, Victor Ferreira, Woranna Dunda and Yohannes Wodajo. Over 75% of the children had been ill, either with fever or with diarrhoea in the week before the survey and 11 children died in the four days it took to carry out the research. Less than 15% of the children had any sign of being immunised against any disease.
Despite the green outlook, the team found only 6% of the population is using their own harvest. Two thirds of families are eating only one meal a day with the same proportion of the population consuming only ensette, or the ‘false banana’ root that is starchy but nutritionally poor.
Visiting the farming community of Sore Mashido in nearby Bolosso woreda earlier this week WHO found families without even have false banana left who are reduced to boiling grass, mildly narcotic weeds and toxic tree leaves for their children.
In the nearby community of Buge Wanchi, the community head said 68 people, predominantly children under five, have died of starvation in the past month and three to four people are dying every day.
"One household even tried to eat the roots of the real banana, which are inedible, and lost three members from poisoning," said acting health bureau head, Mr Yakub Shanka, adding that what really made him wake up to the scale of the suffering was finding a skeletal baby clamped to the breast of its mother who had just died.
Adult malnutrition, much less death, is a deeply worrying sign, according to Dr Kelemu. "Adults only die of malnutrition when the situation is very bad, and we have started to see adult malnutrition in the hospital."
Concern have just completed a first round of general and supplementary food distribution for children in Damot Weyde and have committed to two months of supplies in the hopes that by then either the harvest or government distributions will come through. But they are unable to provide families with full rations and government distributions are slow to arrive here, partly perhaps the international focus on the ‘grey’ hunger of the Ogadon.
Working to WHO technical guidelines for emergency treatment of severely malnourished children, the NGO has set up three therapeutic feeding stations to help the 1,100 severely malnourished children identified so far by their house-to-house teams. They expect to find at least another 700 incoming weeks and are considering opening two more, says Concern’s paediatrician Dr Therese Martin.
"These children are a real challenge to us medically because they are coming in so late, they are immuno-suppressed and highly oedematous – more than 60% of the children are kwashikor.
"The green around us is very deceptive. We’ve had a week of rain and it’s brought the short grass out, but it also washed away some of the young corn. In the short term I am positive that what’s being done can help but in the long term, the health infrastructure is barely functioning."
WHO adviser, Dr Tefarre Wonde, a former minister of health and expert in infectious diseases, says food is an obvious priority. But circumstances such as those in North OMO clearly show that improving access to healthcare and effective systems of prevention such as nutritional and communicable disease surveillance and rapid treatment are crucial to survival in natural emergencies and their development must run alongside food distribution.
"You can’t put malnutrition on its own," he says, "Diseases cause malnutrition and malnutrition causes disease. It’s a terrible synergy."
"We’re trying to save lives," adds Mr Mulugeta Gebru, WHO Ethiopia Emergency and Humanitarian Action programme manager, "But in the long term people need to learn how to manage health services better. This means improving utilization of current resources – not what we wish to have, building capacity through training, logistic support, technical advice. But sometimes we do have to go in with drugs and save lives – if someone is suffering from cholera, they want treatment now, or they won’t survive to listen to your advice on boiling their water!"
WHO is currently working to recruit a nutrition specialist to aid relief workers in drought areas and will run an emergency
updating and training course in surveillance and management of epidemic diseases for health officers from the drought affected zones in mid July.
In the long term, however, the problem in North Omo goes beyond drought and relief aid. The area, say officials, is simply overpopulated and the only long term solution is resettling some of the population elsewhere. But that ‘elsewhere’ is high-risk malaria land where, in 1986, 200 of 500 family heads resettled from the Wolaita woreda died from malaria. Preparing the land through spraying, and protecting the newly settled with early warning systems and treatment supplies will be crucial.
From Concern survey in Damot Weyde April 14-19, 2000, population 179,000
- 54% fever, mostly malarial
- 36% diarrhoea
At Concern therapeutic feeding centres in one month:
(For further information, please contact Concern in Addis Ababa, +251 1 61 1730 or WHO Ethiopia, +251 1 53 1550)
Taskforces for health and hunger
WHO Representative has been leading the Health Taskforce, the international emergency advisory forum for Ministry of Health and co-ordinating body for international agency activities since the beginning of the emergency. Plans are to move to encourage more NGOs at the next meeting on 23 June.
A similar Nutrition Taskforce has also been recently set up under the chairmanship of UNICEF. WHO technical advisor on maternal and child health, Dr Abonesh Hailemairiam and Dr Elio Giombini, WHO consultant epidemiologist for the Horn of Africa are part of the group which also includes the Ministry of Health, members of the Disaster Prevention and Preparedness Committee, other UN agencies and NGOs.
The immediate tasks, says Dr Abonesh, are to update the guidelines for nutritional help during the emergency, review the figures for those needing help, develop simplified tools for surveillance and monitoring of malnutrition and train community health workers. In the process, the taskforce wants to make an inventory of what organisations are doing what and where.
(For further information and meeting times, please contact the WHO Office, Addis Ababa +251 1 53 1550 or firstname.lastname@example.org)
Measles challenges logistics
In some places in Ethiopia, the only way to get the cold chain in place for immunization is to carry the fridge for three days into the mountains on your shoulders. It’s this kind of logistics that has challenged the small but perfectly formed WHO Ethiopia Expanded Programme of Immunisation team in planning the measles and vitamin A campaign due to start on 23 June.
The campaign, instigated and funded by UNICEF and planned and implemented jointly by WHO and local district health teams, the campaign will target 2.16 children in 18 of the drought-stricken, most remote and undeveloped zones.
Physical weakness from lack of food plus, in some cases, population displacement due to the drought has increased the already high risk of measles epidemics among these largely unvaccinated children and major outbreaks in Ethiopia often kill up to 20% of their victims.
In a funding drive throughout the world, UNICEF has garnered large sums of money and is providing the necessary supplies. But working out exactly how to get these to the children has also been far from easy. Many are far from main transport routes. So the logistics team led by WHO EPI logistician Bertrand Jacquet have worked out individual routes for vaccines and equipment delivery based on the facility by facility detailed inventory he and his team have compiled over the past three years (see below)
Organisation of the campaign has taken one month – not bad, says Jacquet, for a supposedly ‘non-operational’ agency.
"WHO is getting more and more operational in EPI. We still need to speed up a bit – mainly in getting supplies and accessing money – to really react fast to an emergency epidemic, but our detailed knowledge gives us a head start."
In fact, in Ethiopia at present WHO is the only health-related agency to have the in- country logistic capacity to run immunization campaigns.
The campaign will start in the Southern Nations, Nationalities and Peoples Region on 23 June. Other zones, because of administrative commitments, will follow in late June and early July. Though specifically hitting areas suffering under the drought, the campaign strategy also fits well with the Government’s three year accelerated measles programme which has seen almost all children in more accessible areas vaccinated over the last two years.
Pilot sends SOS to remote regions
What do you do if mothers in remote areas can’t or won’t bring their babies to you for their childhood vaccinations? Easy, says Dr Angela Benson, WHO’s medical officer in charge of the routine immunization programme, "You go to them."
Well, not so easy in fact, she adds. The idea of taking routine immunization, not just national campaigns out to the people, has been controversial not least because of the logistically difficulty of keeping vaccines in good condition and adhering to optimal schedule timings.
But says Dr Benson: "We argue that the traditional way of providing routine childhood immunization, that is sit in a health station and invite mothers and their children to come to you, doesn’t work in a place where there’s no equipment, sparse population, large distances and extraordinarily difficult terrain – in some places you have to lower vaccines into the valley by rope. But National Immunization Day (NID) campaigns against polio carried in these same areas do work, so why can’t we use the same strategies for routine immunization?
Hard to reach: 1999 EPI coverage:
This rationale is the basis of a unique programme called Sustained Outreach Services – or SOS – that has been used so far in Uganda, Mali, Mozambique and Ghana and is about to be piloted in Ethiopia.
What SOS does, says Benson, is take the essentials of NID operations – the time-sensitive planning, the extra resources for cold chain, transport, human resources and training, the intensive public awareness raising activities – and apply them to providing routine immunization.
"This means doing micro-planning at woreda (district) level. You have to know, for example, how often it is feasible for mothers to get to a certain point, how to get vaccines, vaccinators and mothers to that point exactly on time. For NIDs you do that and finish, but with SOS we will need to do this every two to three months in each area. What we are aiming for is to make sure that children have contact with routine immunization at least four times a year."
The vaccine schedule will include the normal childhood antigens – diphtheria, pertussus, tetanus (DPT), oral polio, BCG against tuberculosis and measles vaccine. Ideally the multi-dose childhood vaccines should be given over two consecutive months but though the longer schedule means protection is delayed, it is better than the alternative – no vaccine at all.
The WHO EPI team will start piloting SOS for the first time in Ethiopia in the autumn thanks to a US$900,000 donation from the US Agency for International Development (USAID). Some $780,000 has come to WHO to cover the technical design, planning and operation of the programme while the remainder has been allocated to UNICEF to procure cold chain equipment and spares.
Of the 10 pilot zones chosen, 8 are in the most remote and underdeveloped areas of Afar, Gambela, Benishangul and Somali, where the population is often nomadic. The other two reflect pockets of low coverage in Oromiya and Amhara.
"In 1998-1999, immunization days in Afar and Somali increased polio coverage by 85% and 105% respectively," says Dr Benson. "We believe that using the same kind of approach, we should be able to get coverage for all vaccines in these difficult regions up to about 60% by the end of this year and to 80% in 2001."
Giving their time…. and their lives
Vaccination saves millions of lives, but it can also be life-threatening for the thousands of volunteers who take part in a country where both terrain and political differences can kill. Nine health workers died during last year’s polio campaign in Ethiopian Somali, four from land mine explosions, three from gunshots and three in road accidents. There have also been numerous injuries largely from traffic accidents.
Desperately seeking spare parts
Three cars, six logisticians and six months is what it took to give Ethiopia its first full inventory of the cold chain. The small team of WHO and national staff travelled 11 regions, 71 zones and 1.2 million square kilometres on rugged roads, foot trails and donkey paths to assess each and every health facility in the country. The results not only fill a major gap in management knowledge by providing a comprehensive and costed list of requirements for spare parts and supplies, but give insight into the whereabouts and state of every health facility in the country - information invaluable for all kinds of logistical planning.
The EPI team are now seeking donations of US$360,000 needed for this year to do repairs and bring spare part stocks up to a basic minimum. If this can be done, the ongoing requirement in subsequent years will be less than half this amount.
For further information or a copy of the inventory document, please contact Bertrand Jacquet, EPI logistics officer, WHO Ethiopia, +251 1 534 808, email: email@example.com
Taking the heat off the cold chain
Until this year, the Ethiopian health service had just one expert repair person to call on when the gremlins got into their cold chain. Not surprisingly he was a hard man to catch. Now the Ministry of Health has agreed to let the cold chain maestro work on training a whole new generation of technicians with the help of WHO to ensure that expertise is available in every region.
The first training of 25 trainers of trainers took place last month under the guidance of the Ministry of Health, the Ethiopian Science Commission and World Health Organization In July and August, the course will be rolled out to over 240 people working at the coal face in the zones.
It’s unlikely, however, to be the last training. High staff movement in the health facilities mean regions often lose their skilled labour. "One of the problems in Ethiopia," says WHO EPI team leader Dr Robert Kezaala, "is that the rapid decentralization (that took place with the arrival of the federal system) means regions have very little expertise in such things as vaccine storage, cold chain management, negotiating with donors, training and supervision – which in other countries would be done centrally."
The Somali region, for example, has had to return millions of Birr (Ethiopian currency) to the central coffers simply because they do not have the manpower carry out EPI work.
Ethiopia is a strong country, says Dr Kazaala, originally from Uganda, "but this rapid decentralisation, poor resources, very difficult terrain and a vast country means they need a lot more help than many other countries in Africa."
WHO has also started training grass roots immunisation logisticians in skills such as how to manage and store vaccines, estimate needs and plan distribution.
"The main challenge for the future is to supervise these people and make sure they are well supported and motivated to continue. This will make a big improvement in the logistics system which basically doesn’t exist at the moment, " says WHO logistician in Addis Ababa, Bertrand Jacquet. Management of supplies at the central warehouse is also being revamped.
Budding field epidemiologists from every region in Ethiopia will gather in mid July to improve their communicable diseases surveillance skills.
Based on the WHO African Regional Office’s innovative Integrated Disease Surveillance system (IDS), the course is organised by WHO, sponsored by the Israeli Government, which is funding expert lecturers, and backed by the Ministry of Health which has recently refined the existing 76 condition surveillance system down to target 17 priority diseases. Management guidelines and reporting methods have also been revised.
The implementation of the new surveillance system itself is being funded by USAID and UNICEF. The crucial area for development is at district level, says Dr Eyob Tsegaye, WHO’s communicable disease expert. "The regional level is pretty good, they get information immediately to the ministry. The problem is getting the information below that. How, for example, can a health worker report a single case of cholera in a time scale that makes it still useful?"
Response to epidemics is also poor at the zone level. But Dr Eyob is optimistic: "Given stability, within a year I think we could create a mechanism where we basically know what is happening and where, and develop a reasonable epidemic response capacity."
Building this capacity is one of the key elements detailed for funding in WHO’s Action Plan for the Horn of Africa, launched in concert with the UN’s Appeal for the Drought earlier this month.
Preparing for meningitis
Many of the vaccine supplies brought into Ethiopia for the March meningitis season have been able to be stockpiled to prepare for the next risk period in December.
WHO has provided around US$45,000 worth of meningitis supplies – some 100,000 doses – this year which has so far proved to be mild one for the disease in Ethiopian terms. There have been two outbreaks of around 100 cases each in South Tigray and North Gondor, while another occurred in April in Gambela. All were different strains and were reported early, enabling a quick control response.
As a result, WHO believes there are adequate stockpiles in the country particularly given the difficult of maintaining quality., plus says WHO representative Dr Michel Jancloes, because the new meningitis unit established at WHO Headquarters now provides rapid access to both money and supplies in an emergency. The high risk time returns in January, although displacement of population brings its own out of season risks.
Small outbreaks but still fears
With over 75% of Ethiopia considered high risk malaria land, WHO has been concerned about the potential for epidemic outbreaks with the sporadic onset of rains.
Overall these fears have, fortunately, so far not been fulfilled, though some areas have had small outbreaks, says WHO communicable disease expert Dr Eyob Tsegaye. But, he notes, "together with AIDS/HIV, malaria is the number one health problem in this country and the next dangerous period – late August and September – is not far away."
Moisture and high temperatures ring alarm bells for Mr Dossa Mada, head of the North Omo zone health department where 18 out of 22 woreda are malarial. His population has been hit by two outbreaks in the past three years: one as the drought took hold and ponds stagnated in the high temperatures producing ideal breeding ground for the anopheles mosquito, and the second now as mosquitoes breed in the puddles left over from sporadic rains.
An investigation of an outbreak a month ago in Sore Mashido community in Bolosso woreda (district), confirmed 25 out of 30 samples were falciparum, with the remainder vivax. Three people died before the investigating team arrived.
This epidemic was halted with a combination of spraying, mass treatment with Fansidar and community education which, together with impregnated bed nets, are the major measures promoted by World Health Organization, advice which the Health Ministry has now incorporated into its five year health sector plan.
The plan was fine-tuned at a 300-strong ‘Roll Back Malaria’ national conference sponsored by WHO in February, and forms the basis of the malaria section in WHO’s Action Plan for the Drought in the Horn of Africa, launched last week.
In the community of Bushelo on the outskirts of SNNP regional capital Awasa, the Fransiscan Sisters who run the 20-year-old ‘Major Health Centre’ put their 75% drop in both in-patient and out-patient cases of malaria between 1997-1998 and 1999 down to household spraying.
Many regions complain of lack of money to buy supplies. But Dr Eyob says: "This is the first time comprehensive malaria activities have been included in the health sector plan. If we can sell the action plan to donors, things will improve."
Roughly US$6.2 million are needed per year to carry out the Government’s plan for malaria. Drug costs have gone up with the increasing incidence of the most dangerous form of malaria, falciparum, which means the more expensive fansidar has to be used as first line treatment in most areas. There has also been little vector control work done, a crucial element since cases of malaria are now appearing at altitudes of over 2000 metres, a previously unheard of occurrence.
For further information, please contact Dr Eyob, WHO Ethiopia
Access to health
Reform needs good managers
Political decentralization has laid a good foundation for improving access to health but there’s a long way to go before patients really feel the benefit.
That was the conclusion of a 100-participant workshop held this week (12-14 June) to explore the results of research carried out by WHO and the South Nations, Nationalities and Peoples Region Health Bureau into the progress of health reforms which aim to dramatically increase the number of health facilities in remote areas.
The country has been undergoing a process of decentralization of all political structures since 1991. Nine new autonomous federal regions have been set up. Within them are a number of zones. which each break down into woreda or districts while below them and closest to the people are the kebele or community councils.
This federal system means the Ministry of Health is mainly responsible for the development of policy, but has little clout to enforce its recommendations in the regions.
Working with the Ministry of Health, WHO has grasped decentralisation as an opportunity to find ways of improving the abysmal provision of health services in rural and remoter areas.
But the research suggested much work was needed to help health bureaus and offices at regional level understand and carry out their new powers and functions.
"The burden of disease and problems in health service management have not shown any improvement given the increased budget share and staff," said the report authors.
One of the key problems said Dr Gebre Meskel, head of the Ministry of Health’s planning section who attended the workshop, is the lack of management capacity among health staff, an area that WHO hopes to provide training help.
Dr Hailemarian Kahassy, from the Office of Health Services Development in WHO Geneva told the conference WHO could play a key role in helping to train such managers and the teams of clinical staff that are planned the new health facilities that are scheduled to accompany decentralisation.
Hospitals under pressure
Soddo Hospital is characteristic of many district hospitals in Ethiopia. Built by the Sudanese International Missionaries, it has seen little repair work and less new equipment since its opening in the 1970s.
Now, however, it is under even more pressure. Not only are increasing numbers of drought-affected patients needing care for the deadly combination of mal-nourishment and clinical illness, but the hospital, like all others in Ethiopia, has no allocation to buy medicines and drought-affected patients with little or no income have no money to pay.
In addition, the food allocation in medical director Dr Kelemu Desta’s budget, fixed long before the onset of the current food shortage, is nowhere near enough to provide food for the severely malnourished sick children who are referred to the hospital.
"I have no medicine, no budget for food to feed these children. When Concern need to refer a patient from one of their feeding centres, I tell them I can put a mattress on the floor, I can look after them, but I can’t feed them."
In the food area, at least, some hope maybe in sight. International health NGO World Vision have agreed to set up a therapeutic feeding centre in the hospital which will care for up to 30 children a month, and Concern is providing general, supplementary and therapeutic feeding in one nearby woreda.
But medications are another matter. "Every week I observe helplessly the death of least three patients simply because they cannot afford to buy IV fluids. If I have a shock patient with abdominal injury, I can do the operation freely, but if he doesn’t have money for antibiotics for IV fluids, how can I help him out?"
Staff shortages are also a challenge. The 250 bed hospital has eight doctors – one surgeon, a surgery intern and six general physicians. In this time of crisis for women and children particularly, it has no paediatrician nor gynaecologist and no possibility in sight of recruiting either.
"What we urgently need is basic essential drugs and medical supplies. The only sutures I have are those I beg from colleagues abroad."
WHO has supplied roughly US$40,000-worth of emergency medical kits this year, but many more supplies are needed – an estimate of 800 new emergency kits.
WHO in Ethiopia
Ground Floor, UN-ECA Building,
P.O.Box 3069, Addis Ababa
Ph: +251 1 53 1550
Fx: +251 1 51 4037
WHO representative and head of Mission: Dr Michel Jancloes, firstname.lastname@example.org
Emergency programmes and information: Mr Mulugeta Gebru, email@example.com
Communicable diseases: Dr Eyob Tsegaye. firstname.lastname@example.org, Dr Agata
Expanded programme of immunization: Dr Robert Kezaala, email@example.com, Dr Angela Benson, Mr Bertrand Jacquet
Mother and child health, reproductive health and gender issues: Dr Abonesh Hailemariam, firstname.lastname@example.org
Public health in emerging regions : Dr Haddis Teklemedhin
Technical adviser to head of mission: Dr Teferra Wonde
Technical adviser to the UN regional co-ordinator for the drought: Dr Elio Giombini, email@example.com