Health Issues in Africa: A Reporter’s Reflections

After three years covering Africa for the Boston Globe, a few random thoughts about health issues looming ahead on the continent:

With the advent of widespread antiretroviral treatment for AIDS patients, AIDS is thankfully becoming a chronic illness in some of the poorest places on earth. But that presents many new challenges as well.

Take just one example -- hospice care. I spent close to a year with Mamelodi Hospice workers, who served a township of 2 million people outside Pretoria, South Africa. For the last decade, the hospice workers offered help to several thousand patients with HIV or full-blown AIDS; many of them died within weeks. The hospice workers were ``angels of death,'' as one nurse told me. But in the last year, Mamelodi's 18 nurses and caregivers
were administering care to people who were given new life by the AIDS drugs. Very few of their patients died in the last year.
Their jobs are now much more complicated. They have become part social worker and part nurse. They figure out transportation hassles. They arbitrate family disputes. They arrange for children to get to school -- sometimes tracking them down on the streets and driving them there.
As more people go on treatment and gain additional years, national governments and donors will be forced to prepare for what will be a huge increase in community caregivers such as those in Mamelodi.

African nations differ widely in how they handle AIDS and other health problems. Zimbabwe, which not long ago had one of the best health systems on the continent, is in crisis; Botswana, despite having one of the highest rates of HIV infection, is building up its system, thanks to both donors and a growing cadre of national health workers.

Within countries, huge gaps also exist with levels of service and performance. This points to an increasing need for coordination with a country- or district-specific focus -- especially at international meetings, such as the AIDS extravaganza held every two years.

In several African countries, the Global Fund to Fight AIDS, Tuberculosis and Malaria is fairing poorly, especially in its AIDS and malaria programs. Of those poor performers, several, but not all, are in the PEPFAR-focus countries -- part of the Bush administration's $15 billion, five-year AIDS program. Some suggest that poorly staffed health ministries are having trouble juggling both PEPFAR and Global Fund grants, as well as programs from dozens of other donors. Some also suggest that PEPFAR grants are performing much better in these countries because it has experienced staff on the ground.

The question becomes whether the Global Fund needs to alter its architecture to rescue its failing programs. Many argue against it, saying the Global Fund shouldn't become a mini-United Nations. But in the coming months, especially with the election on Oct. 31 of a new Global Fund executive director, there surely will be discussions about the Fund making structural adjustments, or entering into partnerships with other groups, to
help grants in trouble. In Africa, many US AIDS workers are privately very worried that a number of Global Fund programs will collapse.

On HIV prevention, issues closest to the disease attract much attention: counseling and testing; the ``ABC'' philosophy; the possibility that male circumcision may help reduce infections; and widespread treatment, which encourages people to learn their HIV status.

But there's a second ring of prevention issues that also deserve attention and many of them evolve around engaging young people in meaningful activities. These areas include job creation and funding more after-school programs such as sports clubs, choirs, bands, Bible classes, and book clubs. Another idea talked about by Africans: getting
municipalities to enforce drinking laws by shutting down bars by midnight and not serving alcohol to minors.
Looming over all these issues is men's power over women in the vast majority of relationships. No easy solutions exist, but South African programs that reach out to men in hopes of changing how they treat women have had encouraging results. ``Don't write off men,'' one South African told me.

Looking beyond HIV and AIDS, several health initiatives in Africa appear to be saving the lives of untold numbers of children. One very encouraging program has been the drive to vaccinate children against measles in many African countries recently. Encouraging -- if very early -- signs also are emerging from some malaria-control initiatives that combine bednets, indoor spraying, and artemisinin-combination therapy.

Several veteran health specialists around Africa say that if this hopeful trend of childhood survival continues, an increased focus should turn to family planning. Some would argue that family planning all along should be a central health focus in Africa, where women in 23 countries have more than five children on average. (US women have 2.1 children on average.) It appears that the population issue will only grow in importance.

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John Donnelly was the Boston Globe's Africa correspondent from mid-2003 to mid-2006, focusing largely on health and development issues. He is now a reporter in the Globe's Washington bureau. He can be reached at donnelly@globe.com.

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