AFRICAN HEALTH ISSUES

Program 0223
June 4, 2002

This text has been professionally transcribed. However, for timely distribution, it has not been edited or proofread against the tape.


KEITH PORTER: This week on Common Ground cleaning
Kenya’s water.Plus, South
Africa’s fight against
tuberculosis.

KRISTIN
MCHUGH:
Common Ground is a program on world
affairs and the people who shape events. It’s produced by the
Stanley Foundation. I’m Kristin McHugh.

PORTER: And I’m
Keith Porter.

MCHUGH: Tuberculosis kills two
million people around the world each year. The disease is curable, but the
number of sufferers is still expected to grow by a
billion over the next two decades.

PORTER: All but wiped out in Europe and America, this silent epidemic
continues to ravage the developing world, and it’s
getting worse. There are now large numbers of people suffering from mutated
strains of TB, that resist even the best drugs. As Common Ground Correspondent Eric Whitney
reports from South Africa, health officials are
struggling to stop these new super bugs before they’re
out of control.

ERIC WHITNEY: Patients crowd the halls of
this public health clinic on busy Sammy Marks Square in downtown Pretoria, South Africa. Generally
a pretty healthy looking bunch, they wait patiently for attention from one of
the four nurses in their authoritative blue jackets—or maybe the lone doctor to
review a chest x-ray. Miriam Uste is the nurse in
charge.

MIRIAM USTE: Daily we see about 105
people here. On a Monday, Wednesday, and Friday, there’s
sometimes more, sometimes less. Of course Mondays,
Wednesdays, and Fridays we have TB clinic.

WHITNEY: Scenes like this are the
stuff of medical history books in the US and Europe. Only a handful of clinics
on either continent would see this many TB patients in a day,
and most clinics have none at all. After all, TB has been curable since the
1950s. But you wouldn’t know that in South Africa, where Sister Uste doesn’t predict that she’ll be going out of business
anytime soon.

USTE: Yeah, definitely TB is
increasing. I can just explain to you: we admitted, last year 200 patients for
the whole year, and this year we are at 390 patients. So…

WHITNEY: For this clinic?

USTE:
For this clinic. So yeah, its….

WHITNEY: The World Health
Organization says that a country needs to have a cure rate of at least 85
percent to begin solving a tuberculosis epidemic. So far
the Sammy Marks clinic is keeping up as well as any place in South Africa, curing three-quarters of
the patients who come through its doors. Nationwide, only six in ten who get TB
survive.

DR. REFILOE
MATJI:
When
one compares where we started four years back, really there’s
been a major improvement. Because then, 1996, our cure rate was just about 50
percent.

WHITNEY: Dr. Refiloe Matji,
is the TB Control Director for South Africa’s seven-year-old
democratically elected government. From the apartheidera it inherited a poverty-stricken populace and a
patchwork of sometimes contradictory approaches to healthcare. Tuberculosis was
an epidemic that existed underneath the official radar in South Africa for many years.

MATJI:It’s
not that it’s a new problem. It’s just that there were
no monitoring systems and people were not able, did not know how big the
problem is. People are now aware that there is a problem of TB.

WHITNEY: The problem turns out to be
about 250,000 strong and growing. The government spends one hundred million US
dollars a year fighting TB, but health officials expect the number of new
infections to continue growing for at least another decade. In theory, solving
the problem seems simple: the disease is fully curable
with a regimen of antibiotics that only costs about $25 from start to finish. But Dr. Marcos Espinal, a health
officer with the World Health Organization, says it isn’t as easy as it sounds.

DR. MARCOS
ESPINAL:
There’s a misconception that TB only needs drugs. TB also
needs the full strategy, needs the infrastructure of the primary healthcare
sector to deliver that strategy.

WHITNEY: The reason it needs a
strategy is because if the drugs are misused the
bacteria that they’re supposed to be fighting can mutate into
antibiotic-resistant strains, known as multi-drug resistant, or MDR-TB. MDR-TB
is a more efficient killer, and says Espinal,
incredibly expensive to fight.

ESPINAL: In the US, just the treatment regimen
for MDR costs up to $15,000. And when you include
hospitalizations, counseling, etc., etc., it goes to $180,000 per patient.

WHITNEY:South Africa may be a long way from
having its TB epidemic under control. But by at least
adopting the WHO-endorsed treatment strategy, the number of MDR-TB infections
should go down. Dr. Espinal says other developing
countries are making it work, among them Cuba, Vietnam, and Tanzania.

ESPINAL: What I think they have in
common, political will. The government decided to face the issue. The
government put in place their resources, their human resources—financial as
much as they can—to fight this disease. And it can be
done.

WHITNEY:South Africa TB Control
Director Dr. Matji says their country
has the will to fight TB. It’s pledged to find and
treat each and every citizen who gets the disease. But
that’s only one of the challenges here.

MATJI:I’d
like to mention in Africa our problems are not only TB. Malaria is also demanding. We’ve just gone through a cholera epidemic where a lot of
work again had to be put in. So it’s not only
finances, but really it’s that holistic approach.

[sound of a car starting]

WHITNEY: The political will to fight
tuberculosis in South Africa is personified in its nurses, or sisters as they’re called here. They’re the ones who animate the global strategy to fight TB
in local communities. The strategy is called DOTS, an
acronym for Directly Observed Treatment Short course.

SISTER TINY
KAPOLA:
[talking
while driving in a car] I am Sister Tiny Kapola and
then I do Direct Observed Treatment Short courses on clients. Some of them,
they are squatter camp clients who are not employed, who don’t
have places to stay. And then I have to follow them
up, right to the squatter camps. For example, at Marabasdad.

WHITNEY:Marabasdad
is where Sister Kapola spends most of her mornings,
on the dirty streets crowded with walkers, among the hundreds of low shacks
thrown together out of whatever their residents could scavenge. Her job is to
track down patients who are on DOTS and help them stick to the drug regimen.

[Many people talking with Sister Kapola]

WHITNEY: Everyone at Maravasdad seems to know Sister Kapola.
Walking its narrow passageways, she points out many who she’s
helped to cure, like these older women that she finds sitting outside a
makeshift tavern this morning, passing blue plastic pitchers of local beer.

[people talking in the
makeshift tavern]

WHITNEY: TB patients in Marabasdad are more likely to be what public health
practitioners call “defaulters,” which means they’re
prone to stop taking their treatment before the six months necessary to fully
eradicate it from their bodies. If the drugs aren’t
taken religiously, TB can come roaring back and create more dangerous mutant
strains. So Sister Kapola is
careful to track each one down. She tries to be understanding and
nonjudgmental.

KAPOLA: Yeah, those were my
defaulters, but we managed to trace them and got them and then I gave them
treatment regularly until they were discharged.

WHITNEY: So they were former
patients, and now they’re cured?

KAPOLA: Yeah, they are cured. But then you see, they
go back to drinking and all that because they don’t have anything to keep
themselves busy. And there’s nothing that you can do.
You try to advise, but then look at their conditions under which they live. So, it’s very, very, very difficult.

WHITNEY: Sister Kapola’s
efforts don’t go unappreciated. Nor could she be
effective without help from the community that she serves. Sixty-year-old Mama
Lillian is a longtime community activist and one of Sister Kapola’s
best connections. She helps her find those who are in need of treatment and
knows TB signs and symptoms well.

MAMA LILLIAN: It starts like having a flu. Having a flu you cough
continuously. And restless at night. You don’t sleep. They can sleep all, but you never. Even if you don’t cough, there’s no sleep. There’s
that to it. Those joints are always tired, you know. You can’t,
a mouthful of water, you can’t pick it up. There’s
nothing that is nice when you want to eat. Even the very tea you used to drink
you can’t drink it anymore. The taste is no more.

WHITNEY: Only about 10 percent of
people who carry TB bacteria ever become ill with the
disease. But those who do get sick tend to come from
places like Marabasdad. People without steady access
to healthy food, or enough food, and people who are forced to sleep many to a
room, where exposure to someone who’s infected is
constant and inescapable. But that doesn’t mean TB
can’t be defeated here. Mama Lillian is living proof.

MAMA LILLIAN: TB can be
cured. I am one of them. I had TB also. I’m a
TB case, but I’m cured now. But now I’m cured. I don’t even scared to tell the people that TB can be cured,
because I saw it with myself. The wind could blow me left and
right, the way I was first. But I attend the
clinic for six months. And here I am: fit, no wind can
blow me again [laughs].

WHITNEY: There would likely be more success stories like Mama Lillian’s if the
government could afford more nurses like Sister Kapola,
to seek out and monitor everyone who has TB in this large, sprawling country. Many people here still live
lives of subsistence in remote areas. It frustrates public health officials,
like the WHO’sRajish Gupta,
that the problem simply isn’t being solved when a proven strategy exists to
beat it.

RAJISH GUPTA: In fact, it was rated by the World Bank as one of the most
cost-effective health interventions out of all health interventions. We’ve come up with the strategy. Now there’s
certain things that are just historical processes of the way the world works,
the distribution of resources. And it’s time for the
donor countries and for industrialized countries to really step up to the plate
and do their job.

[sound of a TB patient
coughing]

WHITNEY: The consequences of not
bringing TB under control in South Africaare
played out here, at the JosePearsonTuberculosisHospital in the impoverished Eastern Cape Province. It’s
recently been expanded to add a ward exclusively for patients who suffer from
multi-drug resistant TB. The hospital houses about 350 patients at a time.
Among them on any given day are about 20 children.

[sound of children talking
in the TB hospital]

WHITNEY:It’s
not known exactly how many South Africans suffer from multi-drug resistant
tuberculosis. But it’s estimated that their numbers
grow by about 2,500 a year. Because the drugs to fight MDR-TB are so expensive,
the government and its partners are trying to set up a pilot program that will
allow them to access the medications at a deep discount. But the WHO’s Gupta says that the multinational committee that
controls access to the cheap drugs is reluctant to hand them over to countries
like South Africa—countries without a strong
track record of fighting ordinary TB.

GUPTA: The drugs to treat MDR-TB, it’s kind of like the last line of defense against TB. In
the last 20 years there’s only been 13 out of 1,300
new molecular entities for infectious disease use. That’s
not good. So we have to do good with what we have for
right now. And with second-line drugs, those are a
last line of defense. So we have to protect their use.

WHITNEY: But Gupta says the WHO is
not abandoning those countries that don’t qualify for
the new lower drug prices. He says it offers assistance in building the
capacity to beat ordinary TB, using the Directly Observed Treatment Strategy,
or DOTS, which is the foundation of fighting MDR-TB.

GUPTA: It can really only be
conducted in areas with a good DOTS program, because it’s
a simple principle. If you can’t manage patients for six months, for
drug-susceptible TB, then how are you gonna
manage this drug-resistant TB which requires 18 months of treatment, and a lot
more complexities?

[sound of people and
vehicles in a busy area]

WHITNEY: Back in the squatter camp
of Marabasdad, these debates over global health
policy seem very far away. Sister Kapola and the
other nurses who care for the TB patients here are simply doing the best they
can with what resources they have. Should South Africa’s government decide to
start distributing the new AIDS drugs to its citizens, they’re
optimistic that they could administer them well. They’ve
already won the people’s trust. For Common
Ground
, I’m Eric Whitney in Pretoria, South Africa.

PORTER: And I’m
Keith Porter. Nearly two billion people around the world don’t
have safe drinking water. The United Nations says more than three million
people a year die from drinking dirty water. Most of them are children and the
elderly.

MCHUGH:It’s
been a problem for hundreds of years, mostly because piping clean water to
those who lack it is complicated and expensive. But as
Common Ground’s Eric Whitney reports,
eight agencies are finding success with a more affordable local alternative.

[sound of children playing
in a river]

ERIC WHITNEY: Under the blazing tropical
sun a boy and his sister splash in the KujaRiver in Kenya’s rural west. They bathe as
their mother washes clothes beneath the trees on the river
bank.

[sound of children playing
in a river, and their mother talking to them]

WHITNEY: The dark swift river cuts
through high, red clay banks and this low spot next to an incoming creek is a
favored watering hole for livestock. Many people drink this water as well.

LORNA OKO: [via a translator] I’ve come to fetch water from the river.

WHITNEY: After walking from the
nearby village of Sasi, Lorna Oko
and her boy and girl on this visit are filling three large plastic jugs.

OKO: [via a translator] I’m going to use it for cooking.

WHITNEY: More than one billion
people around the world don’t have access to tap
water. For them, this is a daily scene. Dr. Rob Quick is a clean water
specialist with the US Centers for Disease Control, or CDC. He says that with
conditions like this it’s no wonder that two
to three million people a year, mostly children, die from water-borne diseases.

ROB QUICK: Even though this is a lovely green spot with lots of bushes, some
grass by the side that the animals like to munch on, and the trickle of this
stream next to us, it’s also an area that is a potential problem for the people
who come down to this river to collect water, to drink, and to cook, and for
other purposes.

WHITNEY:That’s
because even though thousands of people live along and use this river there are
few sanitary outhouses. Toilets and sewage treatment are uncommon. When it rains human waste gets washed into the river.

QUICK: If we were to culture this
water now we would find many colonies of e-coli
growing, which is a sign of fecal contamination of the water. And where there’s feces there’s the potential for disease,
because that’s a way that pathogens are transmitted from one person to another.
So this water is undoubtedly very contaminated and is
not an ideal source. But it’s the only source for the
people who live around here.

WHITNEY: The humanitarian group CARE
is helping the subsistence farmers who live in this area to drill wells and
build sanitary toilets. Both measures help reduce water-borne illnesses. But it’s slow process. Bringing clean water to everyone in
the world who can’t get it now is a project measured
in decades and billions of dollars. But that doesn’t
mean that regular people like Lorna Oko can’t learn
to make their own water safe.

OKO: [via a translator] There are ways we used to use for making this water safe.
That is before the coming of chlorine. So before we had the chlorine we used to
boil it, boil the drinking water. But now we are using
chlorine to make it safe for drinking.

WHITNEY: Chlorine is an effective
killer of almost all the bad bugs in water, which is why city water systems all
over the world add it or other disinfectants to what comes out of people’s
taps. Because the people here have no taps, CARE and the CDC started supplying
chlorine directly to the public. After a substantial marketing campaign more
than a third of the people in this area are now chlorinating their own water
routinely.

OKO: [via a translator] Using chlorine is much safer and easier than boiling the
drinking water.

WHITNEY: Chlorine is generally cheap
and easy to find around the world. But in remote
places it can be made easily by the locals. All it takes is water, salt, and a
little electricity. And it only takes a tiny amount to
treat many liters of water. Oko says some are wary of
the new liquid, but not her.

OKO: [via a translator] Most people who are not using chlorine are saying that it’s
a birth control method, so that is why most people are not using chlorine.

WHITNEY: Do you think it’s true?

OKO: [via a translator] I’m still giving birth! [laughs] I
can still give birth. [laughs some more]

WHITNEY:Oko
says the impact of many people chlorinating the water in her village has been
dramatic.

OKO: [via a translator] The difference that we’ve noticed is in the reduction of
children’s deaths. Before we started using chlorine—that is
when we were, we were just drawing water from here and not boiling and
not treating. There were very many cases of children dying from diarrheal diseases. But since we
started using chlorine the children, the deaths are reduced. That is, the deaths
as a result of diarrhea have reduced drastically.

WHITNEY: Still, convincing people to
start pouring a chemical they’ve never heard of into
their water is a pretty significant task. Another, says, Dr. Quick, is keeping
treated water clean once it’s in the house. That’s why CARE and the CDC try to sell the locals on a
special plastic jug designed to work in tandem with a bottled chlorine
solution.

QUICK: Many people in developing
countries store water in buckets or clay pots with wide mouths. We’ve shown in several studies in outbreak situations that
dipping a cub in the water can lead people to touch the water with their hands
and contaminate the water. So we’ve developed a simple type of container that
has a narrower mouth than normal but it’s open just wide
enough for a hand to get in to clean a container. It has a cap. And then we have another opening that has a spigot on it—a
tap. This essentially gives someone a tap in their home even if they don’t have access to a network. Hands cannot get into these containers.
And the water, once disinfected, is kept safe.

WHITNEY: Introducing the sealed
plastic safe water containers and training people to properly use chlorine has
drastically cut rates of intestinal diseases in many communities, sometimes by
as much as half.

[sound of someone banging
on a pipe]

WHITNEY: But in this part of Kenya, where there’s
a lot of intestinal disease, the native Luo people
were reluctant to use the new plastic containers. That’s
because of a centuries old tradition of keeping drinking water in clay pots.
Dr. Rob Quick.

QUICK: It keeps the water cooler.
It gives a taste that’s pleasing to the people here. So we married together our idea of how to make water safe
with their idea of what makes water appealing. And we
have requested a local woman’s pottery collective to make clay pots that have a
narrow mouth that have a fitted ceramic lid and have a tap or a spigot on it
for removing the water.

WHITNEY: Tests show that the clay
pots don’t diminish the chlorine’s effectiveness and
demand for the modified ceramic water pots is strongly outstripping supply. Which is good news for these women.

[sound of women singing and
chanting]

WHITNEY: Singing while they work,
these women are part of the collective that makes the modified clay pots which
CARE and the CDC help distribute. They’re known as the
Oriang Women’s Group.

[sound of women singing and
chanting]

WHITNEY: The collective has been here since 1989 and employs scores of women.It’s
never been as busy as now, though. Collective Chairwoman FilgonaAuma says that’s because
demand is huge for the new clay water pots endorsed by the CDC and CARE.

FILGONA AUMA: [via a translator] Since
the CARE ordered for the pots, the major work that they’ve
been doing is just the CARE pots. Because they are not yet through with the
work they are supposed to, the contract says. So they want to make as many as possible, but others
no—their only concentration is on CARE pots, no other business.

WHITNEY: Marketing a simple home
water system like this one—focused on a vessel with a tap paired with
chlorine—has proven effective from Zambia to Bolivia. But
it’s never been taken up as quickly as it has here, among the Luo people on the Kenyan shores of Lake Victoria. The CDC’s Dr. Quick
credits strong ground work in political organizing by
CARE.

[sound of people making
pots]

WHITNEY: And the cultural affinity
for clay water vessels here actually gives HomaBay a leg up on other places
where this clean water system has been set up. Instead of having to import the
manufactured safe water jugs Luos can make their own
here. And because pottery is traditionally a women’s
trade that’s created a rare opportunity in rural East Africa—a chance for uneducated
women to participate in the cash economy.

AUMA: [explained by a translator]
Any woman can hardly make any money from outside
besides making pots here. Because what she’s saying,
even them initially, before they is formed a group, they were doing the same
jobs and it wasn’t rewarding them. And that’s why they
came up with the idea of forming a group and starting the pottery. Because she’s saying most of the work that is there is just the
chamber work. Just to go to the firm, but it doesn’t
pay as much as this because it takes about three months for you to realize the
benefit of the firm. But here it takes a day and you
know, you have how much in a day. And it’s such a good
market, as she puts it.

WHITNEY: CARE is looking for more
pottery collectives to ramp up supply here. Public health officials are
encouraged by the local trend. But still, most of the
African continent doesn’t know this safe water method is available yet.

[sound of a rainstorm]

WHITNEY: Afternoon rains sweep
across the Kenya-Uganda border country. Not far over on the Ugandan side at a
rural AIDS hospital, the CDC is studying whether their water vessel can help
people with HIV and AIDS live longer.

[sound
of a motorcycle]

WHITNEY: Every morning Steven Śbandeke and his 11 community health workers hop on
small motorcycles at the hospital and head out into the surrounding bush. They
visit people struggling to scrape a living off of the
land here. People in mud and thatch homes who grow small
patches of cassava, corn, and beans. The people Śbandeke
looks after are part of a study. Some have been provided
with chlorine and safe water vessels. Others received only education on
cleanliness. Śabandeke says the study has
reduced one of the most persistent nuisances of life here.

STEVEN
ŚBANDEKE:

Diarrhea—yeah, it was quite common. In some families where we have not been working it is still common. Except where we have provided
the vessels it has reduced tremendously.

WHITNEY:Śbandeke
says the people he cares for with HIV seem to do better when they’re
provided with the safe water system. But researchers
so far haven’t seen any data that demonstrates this scientifically. The study
is ongoing.

[sound of men singing,
chanting, and speaking in a dramatic fashion]

WHITNEY: As scientists probe for any
angle with which to fight HIV, very old diseases, portrayed as demons by this Kenyan
theater group, continue to plague up to a third of the globe. The safe water
system that the CDC and CARE are promoting here offers one low-cost response which has proven appropriate and effective across a
variety of cultures. The CDC has packaged the entire concept
and gives away advice on implementing a safe water program anywhere in the
world.Organizers are encouraged by its growth over
the years and say they learn more with each implementation. For Common Ground, I’m
Eric Whitney in Homa Bay, Kenya.

[sound of men singing,
chanting, and speaking in a dramatic fashion]

Our theme music was created by B.J. Leiderman. Common Ground was produced and funded by the Stanley Foundation.

Copyright © Stanley Center for Peace and Security