AFRICA
Thought by many to be the birthplace of mankind, this vast, colorful, and mysterious continent has captivated the world's collective imagination for centuries. Unfortunately, to many of us peering in from the outside, it's also become synonymous with political unrest, war, and a multitude of health crises. Needless to say, the impact that these factors have on the African populace has been no less than devastating. Inadequate healthcare in particular is a constant pressing concern throughout the continent, with a lack of resources, destructive longstanding traditions, corruption, and bad practice standing in the way of sufficient progress. Even so, a transformation is under way. A new generation of African researchers and health practitioners are taking ownership where it counts, combating the spread of disease, poor practice, and cultural barriers and paving the way for a safer and healthier and happier future for the continent's populace.
In May this year, the Joanna Briggs Institute hosted ten African researchers as part of its Clinical Fellowship Program, each specializing in a unique, but significant, area of healthcare. Some of these included: Ugandans Christine Muhamuza and Richard Mangwi; Kenyans Dr. Clifford Mwita, Monica Mirigo, and Timothy Panga, and Bitiya Wossen Admassu from Ethiopia. This article is but a snapshot of the inspired research that these deeply caring and highly motivated individuals are carrying out throughout the course of the year.
Ugandan Clinical Fellow Christine Muhamuza lost her mother to a motor accident in 1998 while she was a high school student. The loss was further compounded by the fact that her mother was her family's sole breadwinner due to the untimely passing of her father four years earlier from AIDS. Muhamuza found her mother's sudden demise all the more heart-wrenching because of its unexpected nature, given her father, by comparison, had suffered slowly for ten years prior to succumbing to the virus. Sadly, she concedes orphanhood is not an uncommon problem in Africa, particularly in Uganda's neighbors of South Sudan, the Democratic Republic of Congo, and Kenya.
As the eldest of six, and without any other extended family, she was forced into raising her siblings from a particularly young age, a task hampered by a range of factors. This included a diminished capacity to financially provide proper food, clothing, and shelter for her family. Reminiscing, she recalls that their house was so old they actually feared it would collapse on top of them. As a young guardian, Muhamuza also suffered from a lack of proper parental counselling and guidance. She felt unable to handle important issues in the way that an experienced parent would.
Muhamuza was faced with inadequate funding for her siblings' education, adding they were forced to consider basic needs "luxuries" in order to set aside money for education. As one example, she bemoans the fact that her family was often unable to receive proper medical care as it was regarded by them as a luxury. Yet, despite such obstacles, her family was still able to use their initiative to find proactive strategies to provide for their education, "namely exploring and utilizing any opportunity that would always come our way such as bursaries and support from friends and well-wishers." Thankfully, they also found ways to work, particularly small-scale farming. Still, a lack of decent funding forced Muhamuza to forego her first opportunity to study medicine, instead choosing to take up social sciences. She was, however, able to later study a Masters of Health Services Research, which allowed her to reengage with her first passion: healthcare.
Muhamuza says hospital acquired infections due to poor hand hygiene are a significant problem in Uganda. She notes some of the barriers that hospitals face in trying to control the infections stem from the fact that Uganda is a "resource constrained country" and hospitals experience shortages of core essentials like running water, soap, and clean linen. She also says hospitals are overcrowded with patients, which unfortunately contributes to the spread of infections. Muhamuza explains that in Uganda an unusual problem arises where the cultural dynamic between healthcare workers and patients is such that it is difficult for the latter to request that workers adhere to hygienic treatment measures. So, as a result of this social dilemma, hospital acquired infections continue to be an unnecessary barrier to treatment in Ugandan hospitals. The problem is so prevalent that Muhamuza's own baby suffered from a hospital acquired infection earlier this year.
To say that Ugandan based Clinical Fellow Richard Mangwi is openly critical of the standard of neonatal care in Uganda would be an understatement. "We could comfortably say that neonatal facilities in Uganda do not exist. Even the highest level of neonatal care at the national referral hospital remains rudimentary. These facilities do not exist in district hospitals/general hospitals. Things like incubators, suction pumps, oxygen supplies or ambu-bags are not commonly found in the hospitals." He imagines that such issues would be unheard of in neonatal units in Europe or Australia and sees a sad irony of the situation, musing that "of course this is a pity for a country with one of the highest fertility rates!!" Tellingly, Mangwi is scathing in his assessment of the role of the authorities in contributing to the low rate of hospital based deliveries, calling them a "clear manifestation of peoples' resentment for the way services are organized and offered to them." There are also what Mangwi describes as "prohibitive environmental factors" which prevent Ugandan women from utilizing hospital delivery services, essentially meaning that demand far exceeds supply.
Sadly, Mangwi says there are additional cultural barriers to the uptake of hospital neonatal services with negative societal values attributed to giving birth in a hospital setting. "There is a common belief that to deliver in the hospital is a sign of being weak or cowardly on the part of the woman. Society expects a woman to be able to deliver on her own. This can earn her respect among her peers." Additionally, Mangwi finds expecting mothers often resent taking up the lithotomy position as part of the digital examination process, as they feel it "exposes them unnecessarily," especially as it is a position associated with sexual intercourse. Another social issue is the way in which the placenta is treated following birth. Mangwi says some communities believe that "the placenta is a second baby which must be buried," however, in hospital settings placentas are instead disposed of in a placenta pit.
There are certainly traditional perceptions of pain within a number of African communities, which stand at odds with contemporary Western medical culture, let alone modern, rigorous evidence-based practice. Kenyan pharmacist and Clinical Fellow Timothy Panga says "pain is accepted, expected, and even sometimes celebrated in traditional African settings." Included among the traditional rituals and ceremonies which involve pain is the process of childbirth, where, Panga notes, "mothers who can say they experienced the most pain can be seen to be strong and dependable." This obviously differs greatly from conventional Western midwifery practice in which pain is substantially minimized with the use of an epidural.
Another ritual practiced in a wide number of African communities, which differs greatly from developed countries, is the removal of lower incisor teeth in children around the age of eight. This practice also occurs without analgesia and further, there is an expectation that children neither resist the procedure nor cry, as bravery is perceived as an important virtue. Although there is no definitive reason for this practice, he says there are some views that "the gap left by removing the two lower permanent teeth, was to allow feeding for those with tetanus, once a very common disease in Africa, when the jaw is locked by the disease." He goes on to say that tattooing and circumcision are other cultural conventions that are practiced without the use of anesthesia or analgesia. Panga is studying pain assessment and pharmacological management among children between the ages of 3 and12, as they are at the unique age of being young, yet still able to provide useable information regarding their pain, or as he puts it "generally able to say what they feel." He says his research involves a pain assessment tool that can be used to "qualify" the level of pain experienced by the child subjects.
Panga says that health workers who hail from these communities struggle to reconcile these beliefs with their contemporary medical knowledge. He says the "resulting inadequate knowledge on pain, poor attitudes towards those in pain, not appreciating the individual and subjective nature of pain will remain a barrier to adequate pain control and responsive pain services." Panga observes that even though authorities in Africa take pain treatment seriously, not enough focus is dedicated to prevention measures, noting, "authorities like responding to acute and emergency situations more than they would want to prevent future problems and prepare better for emergency situations." He notes that although appropriate pain assessment is advocated for and caregivers are expected to adhere to it, proper systems are not in place to assist them in this process. Despite the perceived cultural barriers to pain mitigation in the healthcare process, he retains a degree of cynicism as to the source of the problem: "a system that does not learn from the challenges faced, especially in pain assessment and management, cannot be said to be serious about the plight of our patients. One may easily blame it on our cultural background, but it is difficult for an objective observer to tell whether that is a reason or an excuse."
One of the more obscure problems to emanate from the lack of organization and structure in African hospitals is infection and injury caused by poor management of sharp instruments. Sharp injury prevention is a cause for concern at Jimma University Specialised Hospital in Ethiopia where Clinical Fellow Bitiya Wossen Admassu is based. Admassu says the most common infections that occur as a result of sharp injury are hepatitis B, hepatitis C and HIV, while the range of sharp instruments used at Jimma University Hospital include scalpel blades, sutures, hypodermic needles, blood collection devices, or phlebotomy devices and arteries.
Admassu says the rate of compliance with sharp injury prevention is often less than optimal, due to a range of reasons. She lists these as "lack of appropriate accessible sharp equipment, high patient to staff ratios, shortage of sharp disposal devices, misplacement of sharp material and safety devices, overflow of sharps from the safety devices and insufficient knowledge of staff about risks and procedures." She says there are two key ways in which sharp injuries tend to occur: through the process of administering an injection, or though problematic disposal of sharp implements. She says healthcare workers can be exposed to risk of sharp injury while treating patients through: "recapping of syringes, passing sharp materials with two hands, and being unable to use the free zone especially in operating room." In terms of disposal of sharp implements, most safety bins she observed in Jimma Hospital were incorrectly placed and overfilled above recommended capacity. To add to this, sharps were at times discarded with other wastes.
According to Admassu, there are several barriers which hinder the implementation of evidence-based procedure with regard to the management of sharp implements in African health facilities. First, she states that not only are the facilities for disposing of sharp materials inadequate across the healthcare sector, but there is a lack of protocol with regard to prevention of sharp injury. More broadly, she states there is no regional surveillance system for monitoring occupational infection rates in African developing countries, the ratio of healthcare workers to patients is inadequate, and the knowledge base of health practitioners is not where it should be.
Oddly enough, it appears that despite the publicity given to the spread of diseases and the lack of resources, some areas of Africa are starting to show signs of more "first world problems." Clifford Mwita, a Clinical Fellow from Kenya says his country is experiencing an increase "in illnesses associated with affluence and sedentary lifestyles." These problems, more commonly associated with developed countries, include obesity, hypertension, and diabetes, which he says often occur somewhat simultaneously. Hypertension, in particular, is a disease affecting middle and upper middle class demographics in Kenya. Its increasing prevalence within that country correlates with a rise in better living conditions in the wider society at large, particularly greater availability of food. He notes that although Kenya has "a considerable burden of infectious diseases," there is an expectation that as Kenya experiences greater food security, becomes more urbanized, and becomes, what he terms, a "higher income economy," the rate of hypertension in addition to other non-communicable diseases will undergo a significant increase.
Mwita says hypertension is officially said to affect around 75 million people in sub-Saharan Africa. However, he points out that as not all countries in the region were surveyed, the actual figure would be significantly larger. He says as the population gets older, high blood pressure becomes more prevalent. He says publicity for hypertension sufferers is reduced due to the attention given to high profile diseases in Africa like malaria and HIV. However, while hypertension is somewhat reflective of a rise in prosperity in certain demographics in Kenya, the treatment and recognition of it by actual sufferers remains subpar. Clifford laments the fact that while hypertension is treatable by medication, increasingly, Kenyans with the condition go without important timely interventions, perhaps due to their lack of awareness.
In addition to hypertension, the gradual socioeconomic change taking place in parts of Africa does come with other concerning trends. There is a rise in cases of dyspepsia resulting in heartburn and epigastric (upper chest) pain. Monica Mirigo, a Clinical Fellow and also from Kenya, equates this with changes in diet and lifestyle within the Kenyan populace, including a higher fat intake and increases in alcohol consumption and smoking rates. She says french fries sold on roadsides are especially popular and a low cost alternative to healthier meals. She says a serving could be "as cheap as Ksh.20 compared to a proper meal, for example, rice with peas stew, which could cost as much as Ksh. 80 (Kenyan currency). Socioeconomic status will therefore push one to prefer eating the cheaper, unhealthy food." However, she laments the fact that these dietary changes haven't correlated with general health knowledge: "from the small survey I have done, most patients do not know that poor diet contributes to their heartburn." Mirigo attributes this lack of knowledge with the way in which health education is delivered in Kenya: "we are used to relying on text book knowledge in healthcare practice. That's what we are taught in school and most people aren't willing to deviate from the norm." She says unfortunately evidence-based healthcare isn't an established concept in Kenya and not necessarily one that all health practitioners are aware of, and that "others may use evidence to influence their practice but may not know that it's something they could establish as a practice as it is in developed countries."
In Kenya, as with many other African countries, there is a shortage of funding for healthcare due to inadequate financial management. Mirigo attributes this, in part, to corruption and says the ensuing funding shortfall affects the supply of medicine, hospital infrastructure, and the quality of equipment used in health facilities. Further, she adds that government doctors are underpaid, which has an effect on morale and perhaps even more importantly, "most migrate to other countries where the pay is better." On the flip side, she says unfortunately many in the health profession chose to take up medicine related fields because of their high grades and the "handsome paychecks" associated with the profession, rather than due to an interest in health. Mirigo says some people who would have been aspiring to careers in other professions such as economics or computer programming, chose healthcare because of the aforementioned factors - something she observed during her university education in Kenya.
The Clinical Fellowship run by the Joanna Briggs Institute is designed to provide guidance to the visiting researchers, so they can use an evidence-based approach to find improvements, make recommendations, and effectively create a ripple of difference in African healthcare. Clearly, none of the fellows have any illusions of the scale of the problem, but if these individuals are anything to go by, Africa has a wealth of talent in health and there is certainly a silver lining to the darkness that has enveloped the continent for a considerable time. Richard Mangwi, despite his pessimism about the state of neonatal care in Uganda, does offer a few strategies to ensure the effective rollout of healthcare. Primarily, he recommends using community health workers in villages, using a system not unlike the Village Health Teams. He says these can be incorporated within formal health structures, through which they can access information and therefore "ensure a continuity of services between the households and the hospitals." However, from a logistical standpoint he does note that to use community health workers effectively, some of the "challenges of voluntarism" need to be properly managed and dealt with. Specifically, the lack of monetary compensation for volunteers from poor Ugandan backgrounds and the lack of hierarchy and role structure need to be addressed.
There is also perhaps room for optimism in research for pain management with Timothy Panga proudly proclaiming "everyone who can make a change, and sustain that change to ensure that our practices in the management of acute pain are according to best practice, is in the project implementation team." Panga says he is currently completing the baseline audit and (as of the time of this interview in mid-July) in a few weeks will "implement intervention shaped by barriers identified," which he views as a fresh concept in addressing issues in patient care. He says "ultimately, we (trained healthcare providers) will want all the children to be free from pain and its unpleasant complications, especially if pain has been caused by necessary interventions like surgery."
Richard Mangwi's recommendation is rather than merely encouraging people to utilize hospitals, greater effort should be put toward making hospital services more available and further, "organizing them in a way that takes care of people's own emotions and values and therefore making them more acceptable." In terms of his research, he suggests making neonatal services more permanent, for instance being accessible 24 hours, every day of the week. Also, he recommends improving what he terms "continuity of services" between small centers and hospitals, for instance improving the organization of referrals and counter referrals. "Indeed, the wish to increase the rate of hospital deliveries for expecting women is widely shared among health professionals and other policy makers across Uganda. I also notice that this wish is shared by the community members themselves. The demand for hospital delivery among community members is already present."
All in all, the continuing emergence of dedicated African health professionals provides a silver lining to the dark spectre of poor health practice that much of continent has been mired in for decades. Christine Muhamuza, for one, hopes to educate healthcare workers about correct hand hygiene practices and indirectly help reduce the spread of disease. Despite his obvious concerns about the cultural problems involving pain management in Africa, Timothy Panga remains heartened by continued discussions by authorities on best practice, which leads him to think that despite the aforementioned issues, there is a tangible movement to improve pain treatment and prevention.
Even with more contemporary problems, for instance the increased westernization of the Kenyan diet, Monica Mirigo acknowledges the Kenyan Government is slowly coming around. Their initiative to combat this rising problem leaves her hopeful the situation could improve, which will ultimately be good for an increasingly affluent Kenyan populace.
Bitiya Admassu remains optimistic that despite the multitude of problems facing health services in Africa, improvements are being made. She says the health of African people will benefit from improvements to healthcare delivery that are currently in progress, specifically "quality service, training healthcare providers on evidence-based practices, distribution of standard protocols on infection prevention, and appropriate resource allocation and management." She adds that measures to prevent infection will also make a big difference, including immunization against hepatitis B, safe procedures to prevent percutaneous injuries, and postexposure prophylaxis aimed at curtailing further development of disease.
According to Admassu, in order for health outcomes in Africa to progress, programs like the JBI Clinical Fellowship are important for healthcare workers. She says the Fellowship has some significant repercussions for healthcare in Africa in the regions where it is rolled out. It offers participants from different parts of the continent an opportunity to share and compare health research, develops their knowledge of evidence-based practice, and contributes greatly to their knowledge of data analysis and interpretation. Significantly it allows them to develop skills in conducting clinical audits, which she says are particularly applicable for improving the quality of health practices in Africa. She goes so far as to recommend expanding the program to ensure a greater improvement of healthcare.
Looking at the wider picture for healthcare in Africa, Monica Mirigo says "there could be hope for Africans if the medical practitioners appreciate the use of evidence in practice and choose to practice not because of the money or prestige associated with the profession, but because it's their vocation." She says the more that people undertake training in evidence-based healthcare, the more that the practice will spread, via other health professionals. She says there are promising signs for the rollout of evidence-based healthcare, noting that pharmacists she has spoken to about it have "shown great interest." She adds that even some with more experience in healthcare than her have looked at carrying out hospital-based improvements and "coming up with solutions to existing problems." With more people like Mirigo telling practitioners about organizations like the Joanna Briggs Institute and evidence-based healthcare, there are promising signs for the health industry in Africa.