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MSF in Ethiopia, 2005
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The plight of Ethiopia is well known: Recurrent conflicts, chronic drought, rampant poverty and high illiteracy are the norm. In many areas of the country, health care is nearly non-existent. Government statistics suggest that at least half of all Ethiopians have no access to medical care whatsoever. This East African nation lacks infrastructure, and insecurity plagues parts of the country. Ethiopia's economy relies heavily on agriculture, which is almost entirely dependent on rainfall, and many residents exist on food aid from abroad.
In 2004, the government began a drive to move more than two million people away from the arid eastern highlands. While the program has brought the resettlers to more fertile farmland, many have fallen ill from diseases unknown in the highlands. Across Ethiopia, MSF assists in treating those with diseases that cause devastating effects: malaria, kala azar, tuberculosis (TB) and HIV/AIDS.
Bringing TB treatment to nomads
As in numerous other countries across the region, TB is endemic in certain parts of Ethiopia. Treating the semi-nomadic Afar people in the village of Galaha, in the northeastern desert of Ethiopia poses particular challenges (see below). TB patients are usually required to take their daily medication under supervision and without interruption for several months — a requirement that is highly incompatible with the Afar's nomadic lifestyle. Yet, since January 2001, more than 2,500 Afar patients have been cared for in an MSF rural TB treatment center according to a regimen designed especially for nomadic people living with TB. Approximately 40 new patients are admitted each month.
In May 2005, MSF opened a project in the Gambella region of southeastern Ethiopia, one of the country's most neglected areas where TB and HIV/AIDS are common. Using mobile clinics, MSF brings medical care and food to an estimated 60,000 people who have long resided outside the reach of care due to insecurity and seasonal flooding. A health center in Itang, one of the district's poorest areas, is being rehabilitated by MSF, and the team will respond to other health emergencies as needed.
A long-running TB project in the Ogaden region of southeastern Ethiopia, for which MSF had been providing medicines and laboratory equipment, training staff and monitoring implementation, was handed over to regional authorities in June 2005.
Treating kala azar patients
In northwestern Ethiopia, MSF runs programs to treat people — primarily seasonal workers — who have the deadly disease visceral leishmaniasis. The project is operated in Humera, a town in the Tigray region near the border with both Eritrea and Sudan, and in Abdurafi in the Amhara region. Transmitted by sand fly bites, the disease, better known as kala azar, is a growing plague. Once a person is infected, the disease attacks the immune system, causing fever, wasting, an enlarged spleen and anemia. Without treatment, the disease is almost always fatal.
More than 100,000 workers come to this region each year at the start of the rainy season in search of seasonal farm jobs. Most sleep out in the open, where they are particularly vulnerable to sand fly bites. In 2004, MSF organized an information and awareness campaign in which almost 60,000 people participated. Outreach teams also tested more than 4,000 people for the disease and treated 1,700 patients. On average, one-quarter of kala azar patients are co-infected with HIV/AIDS. MSF is the only organization addressing Ethiopia's kala azar problem and is seeking to raise awareness about the disease, promote increased availability of effective drugs and diagnostics, and encourage other national actors to address this health problem.
Providing needed HIV/AIDS care
Ethiopia is no stranger to the HIV/AIDS epidemic. Experts say at least 1.5 million people already have the disease. With a high number of seasonal workers, soldiers and commercial sex workers, Humera faces a particularly high prevalence. MSF continues to expand the AIDS program that it began there in early 2004 through a network of 20 clinics. Patients receive voluntary counseling and testing, care for opportunistic infections and sexually transmitted infections, treatment with life-extending antiretroviral (ARV) medicines and counseling to encourage treatment adherence. By the end of 2005, MSF plans to be treating at least 500 patients with ARVs. Malnourished patients also receive therapeutic feeding from MSF to boost their response to care.
The threat of malaria
In September 2004, advocacy by MSF and other organizations helped convince the Ethiopian government to change the national malaria policy so that artemisininbased combination therapy (ACT) could be introduced. The change in protocol meant that older, no-longer-effective treatments could be replaced with the much more effective drug Coartem. The importance of this development cannot be overstated given the fact that approximately five million people contract the disease in Ethiopia each year.
Yet like the protocol change itself, its implementation has been slow. A lack of Coartem production at the international level and a scarcity of Paracheck kits (an inexpensive and reliable rapid test for P. falciparum malaria) are the principal problems. Meanwhile, thousands continue to die unnecessarily. To counter these problems, MSF has been advocating for rational use of the existing stock, use of rapid diagnostic tests to prevent overuse of medicines, and ACT treatment to ensure that the older, largely ineffective drugs will not be used.
In the MSF project in the Damot Gale district in the southern part of Ethiopia, almost 5,000 malaria cases were confirmed and treated at 10 government health facilities between November 2004 and March 2005. MSF staff support these facilities, which serve a population of an estimated 300,000 people. They also monitor the region for disease outbreaks, distribute mosquito nets and inform the community about health issues. In the Amhara region's Fogera district, MSF offers malaria treatment at one health center and nine government- operated health posts. In the first half of the year, more than 2,200 malaria patients were cared for the MSF teams.
MSF also battles malaria through its primary care programs in Galaha. MSF staff diagnose and treat those with the disease while working on efforts to control its spread. Teams in various parts of the country have established emergency-response networks in case of epidemic outbreaks.
MSF runs a primary health care program in the Cherrati district of the Somali region — home to approximately 75,000 people. The team has also worked to improve hygiene conditions through a water-and-sanitation project. This work will be completed at the end of 2005.
After November 2004, some 2,000 families moved from the Oromiya region to the Guradamole district of the Somalia region. MSF started an emergency intervention to assist both the local and displaced populations (about 60,000 people in total) who required primary care and adequate food. MSF supports the health center in Haro Dibe and runs a therapeutic feeding program.
MSF has worked in Ethiopia since 1984.
MSF is working in Ethiopia's desolate Afar region to treat nomads who are suffering from TB. As herders, the Afars move their animals every three or four months in search of good grazing areas and adequate water. The region's only health facilities are found mostly in towns along the main roads, far from the Afar's pasture land and water sites. The area's remoteness makes it difficult for the Afar to access TB treatment and adhere to the requirements of standard treatment.
Most patients diagnosed with TB must travel daily to a health clinic to receive and be observed taking their medicines. This is part of the WHO strategy to control TB called Directly Observed Treatment Short-course, better known as DOTS. Supervising patients taking their medication is done to avoid having them miss treatments which can lead to treatment failure and to the emergence of resistance to TB drugs.
MSF opened this TB center in 2001 with the aim of providing quality TB treatment adapted to the Afar way of life. Galaha is a crossroads for nomads bringing their herds to the local river. To maximize the chances that the nomads complete their treatment, MSF adapted a program used successfully in Kenya that was designed specially for nomadic populations. Its central idea is the construction of a "patient village" consisting of houses built in the vicinity of the health center. MSF has learned that nomads are willing to stay in one place for a length of time if effective treatment is available and food and housing are supplied. MSF also has staff that speak the nomads' native language, something often lacking in other health facilities.
The Galaha TB center has a capacity for 400 huts which are arranged in three sectors, depending on the risk of contagion. Patients visit the nearby health center daily to be directly observed taking their medicines and then are free to carry on their lives in the village. Patients testing positive for pulmonary TB receive treatment under close supervision for the first four months. After that, they are discharged and provided with a three-month supply of medication, which they administer on their own. They are instructed to return to the center after finishing all of the drugs for a final TB sputum test that will show whether they are cured. "For nomads, this is a good, adapted approach," explains Dr. Ayub, the program's medical coordinator. "They have direct observation for a longer intensive period, but a shorter treatment course.
This allows us to guarantee better their recovery before we discharge them to continue treatment on their own. And they can return to their lives to take care of their animals and earn a living sooner."