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    A child receives the MenAfriVac™ vaccine in Burkina Faso.WHO/Flickr, CC BY-ND

    A number of countries in sub-Saharan Africa – including Mali, Burkina Faso and Niger, collectively known as the meningitis belt– have been repeatedly devastated by overwhelming epidemics of meningitis.

    In 1996-1997 the largest ever recorded epidemic of Group A meningococcal meningitis and septicaemia (MenA) swept across the region. Within a year it had killed more than 25,000 people and left thousands of survivors with lifelong serious after effects such as brain damage, deafness or limb loss.

    The vaccine MenAfriVac® was introduced in 2010. Since then more than 300 million people aged between 1 and 29 years old who live in the meningitis belt have been vaccinated to protect them against MenA. As a result, there has been a big decline in cases of MenA which was previously the main cause of outbreaks. Today, MenA cases are seen only exceptionally.

    But we know that vaccines which help prevent meningococcal disease don’t give lifetime protection. New research we’ve just completed underscores this.

    In a recently published study, funded by the international charity the Meningitis Research Foundation, we discovered that young people in Burkina Faso who were vaccinated against MenA between the ages of 1 and four in 2010 needed a booster dose of the vaccine as early as this year to ensure they remained protected.

    Our research shows that it’s important the world doesn’t become complacent. We must try to build long-term vaccination programmes to control the disease, including ongoing investment into booster vaccination. The challenge is to mobilise funding for booster vaccination, as current funding focuses on the initial mass campaigns and introduction of routine vaccination campaigns for infants.

    What we found

    Our study involved three surveys after the MenAfriVac® campaign in Burkina Faso, one of the countries where the vaccine was first introduced. Our aim was to assess how well the vaccine was continuing to protect people years after the campaign.

    Each survey involved around 600 people aged from six months to 30 years of age. Blood samples were taken from each participant and the time taken to return to pre-vaccination immune levels (measured in the same population in 2008) was estimated.

    This revealed new information about the duration of protection these kinds of vaccines can provide. We found that this was closely linked to the age at which a person was first vaccinated.

    Overall we found that immunity had reduced in all age groups. But we found that children aged 1-4 years at the time of the vaccination campaign soon returned to pre-vaccination immune levels. This means that, eight years on from the mass campaign, they will be susceptible to MenA again.

    Immunity was retained longer in people who were older at the time of the vaccination campaign.

    With a large proportion of people in Burkina Faso still protected, and with the routine immunisation of infants now in place, there will be far less of the MenA bacteria in circulation than there was at the time of the epidemic in the 1990s. This could offer indirect protection to those whose vaccine immunity is soon to wear off.

    But the age cohort thought to be at risk will soon reach adolescence, an age of high risk for meningococcal disease in the meningitis belt. Adolescents were a group severely affected during the MenA epidemics and could be again.

    Way forward

    The MenAfriVac® vaccination campaign was unprecedented in terms of its success in avoiding MenA epidemics in sub-Saharan Africa. But this protection needs to be maintained.

    The findings from this research provides new insights that can be taken into account by public health decision makers, along with financial and programmatic considerations, when planning vaccination strategies.

    It could help inform when booster vaccinations should be introduced to ensure people living in the meningitis belt remain protected.

    The research indicates that action may be needed soon.

    Meningitis and neonatal septicaemia (or sepsis) combined are among the most deadly infections for children under five globally. The combination is responsible for more deaths than malaria, AIDS, measles and tetanus put together. Vaccination is the only way to protect vulnerable groups from meningitis and sepsis. What we need to do is ensure people are protected from infancy and remain protected into adulthood.

    These research findings give us a greater understanding of the immunity that meningococcal vaccines can provide, when booster doses may be needed, and could have implications for future use of vaccines. This could ultimately help to improve control of meningococcal disease globally.

    The Conversation

    Judith Mueller receives funding from the charity Meningitis Research Foundation


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    Zimbabwe needs to reconsider its HIV transmission law.Shutterstock

    In 2001 Zimbabwe introduced the Sexual Offences Act, which criminalised wilful transmission of HIV. Three years later the law was updated to include those who suspected they could be HIV positive but didn’t inform their sexual partners.

    The law allowed people to be criminally charged for deliberately infecting other people with HIV. It came about as a result of activism by women’s rights groups; they sought to empower women who were being recklessly exposed to HIV by rapists and, in some cases, by their partners.

    At the time, very few advances had been made in the fight against HIV and AIDS; the epidemic was classed as an international security threat.

    But that was 20 years ago. A great deal has changed since then. Most importantly, HIV has become a chronic and manageable condition rather than an automatic death sentence. This is not to say it doesn’t remain a very real public health issue: it’s estimated that about 1.55 million Zimbabweans in a country of 14.2 million people are living with HIV.

    And yet Zimbabwe’s punitive law around the transmission of HIV remains on the statute books – and it’s enforced. Today, HIV transmission cases continue to be heard before Zimbabwe’s criminal courts. This is despite the fact that punitive HIV laws are widely acknowledged as undermining a country’s public health policies and strategies.

    Laws like this exist in many places, including a number of US states, Russia, the UK and more than 30 sub-Saharan countries.

    As I’ve shown in my own research, such laws fuel stigma and discrimnation. They also dissuade HIV testing and adherence to treatment. Unless the legal provision in question is revised, it could reverse the gains made in the fight against HIV and AIDS in Zimbabwe by making it seem as though people living with the disease are criminals.

    Proving guilt

    In 2016, two women were charged under the law and found guilty of deliberately transmitting HIV. In 2016, two people approached the country’s Constitutional Court to have their sentences overturned and the legal provision declared unconstitutional.

    They argued that the wording of that part of the law was too ambiguous and uncertain. This, they said, meant it failed to provide protection to citizens as guaranteed by the Constitution. The ambiguity centred on the “real risk” test, which places an expectation on the accused to recognise the risk or possibility that they are HIV positive and so can transmit the virus to another person.

    The applicants argued that this wording was so unreasonably broad that it created a danger of false incrimination. The court disagreed; the applicants lost their legal challenge and their convictions for deliberately infecting partners with HIV were upheld.

    One of the problems with the law’s wording is that it’s extremely difficult to prove the causal link between the actions of the accused and the consequences faced by the victim.

    And, since the law is worded in such a broad fashion, it leaves room for people to be falsely incriminated when relationships breakdown. This was the case with Samukelisiwe Mlilo – one of the applicants in the 2016 Constitutional Court case – whose husband accused her of infecting him with HIV after she reported him to the police for domestic abuse.

    Mlilo was charged under a provision in the criminal code for deliberately transmitting HIV and convicted despite her argument that the state could not prove that she had actually infected him.

    Next steps

    Zimbabwe needs to reconsider this legislation. If it decides that criminalisation is a necessary tool, the wording of the law must be made more explicit and less open to individual interpretation. Only clear cases of criminality – where there is evidence of foresight, negligence and actual intent – should be tried.

    It must also seek to complement public health policies rather than undermining them. The thrust of the law must be to protect all citizens alike rather than encouraging the marginalisation and exclusion of people living with HIV.

    The Conversation

    Candice Chikura-Mtwazi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.


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    Genetic data holds a wealth of health information.CI Photos/Shutterstock

    Genetic technologies are poised to change the world. Want to eradicate a human disease such as cystic fibrosis or improve a person’s ability to run impossible distances or lift unimaginable weights? This may be possible in the future by using something called CRISPR to edit an organism’s genetic makeup. How about rapidly sequencing a newborn’s genome, similar to an early scene in the 1997 movie Gattaca? Next-generation sequencing may make this fiction a reality.

    As these technologies continue to increase in ability and decrease in cost, we may soon be living in an age of genomics-informed health care.

    Unfortunately, the “we” in the previous sentence only applies to at best 7% of the world’s population. For everyone else technologies such as next-generation sequencing and CRISPR gene editing are more science fiction than nonfiction.

    Low or middle-income countries are where this technology is needed the most as they harbor the largest burden of birth defects and genetic diseases. Yet almost all low-income countries and many middle-income countries lack the necessary personnel, technology, infrastructure, and public and medical education capabilities needed to introduce medical genetics services.

    To address this gap, my colleagues and I created the MiGene Family History App. It’s an Android-based mobile application that aims to introduce medical genetics services into low and middle-income countries.

    The app is used by health care providers and collects and stores patient and family histories. It generates personalised genetic counselling information that can be delivered to patients and their families. And the data can also be used for epidemiologic analysis.

    The app has already been piloted in an Ethiopian hospital and has since been rolled out to a teaching hospital in Ghana.

    It’s important to point out that the technology the app uses is far from what’s required to perform genome sequencing or gene editing in Ethiopia. But our work is one of the many preliminary steps needed to bring attention to the need for genetic services in low and middle-income countries.

    Pilot project in Ethiopia

    The MiGene Family History App was designed jointly by teams at the University of Michigan and St. Paul’s Hospital Millennium Medical College in Addis Ababa. It was then programmed by xHub, a technology group in Ethiopia’s capital.

    The first version of the app focuses on paediatric birth defects and genetic diseases. These include heart malformations, Down Syndrome, and neural tube defects. So we launched the app in the Paediatric and Obstetrics and Gynaecology departments at St. Paul’s. We also conducted a study about the app’s value and ease of use.

    MiGene was loaded onto physicians’ and nurses’ tablets. It was then used to collect data in both departments, but with a focus on the general paediatrics ward. The staff told us they found the app easy to use. The app allowed us to provide the hospital with data on the incidence of birth defects and genetic diseases in the institution. For instance, we found that approximately 12% of all admitted patients were affected with a birth defect or genetic disease. Heart malformations and Down Syndrome were the most common conditions present.

    Having this data will help to inform future decisions taken by Ethiopia’s ministry of health. For instance, it can assess the success of interventions such as the country’s folic acid supplementation efforts, which were introduced as a strategy to decrease the incidence of birth defects of the brain, spine, or spinal cord.

    While our study was intentionally small in scope, if use of the MiGene Family History App is expanded to other regions within Ethiopia it will provide more representative population data.

    One of our most interesting findings was that the incidence of birth defects and genetic diseases at St. Paul’s was nearly identical to the incidence of birth defects and genetic diseases in previously studied children’s hospitals in high-income countries.

    This confirms something that geneticists have long known: genetic disease affects everyone and doesn’t discriminate. That’s why it’s so crucial that the benefits of genetic technology are not limited to only those individuals fortunate enough to have been born into a rich country.

    Taking the tech further

    After the success of the pilot study in Ethiopia, MiGene Family History App has been expanded to include adult-onset non-communicable diseases such as cancer, hypertension, diabetes, and cardiovascular disease. It’s still in use at St. Paul’s and is now also being used at Korle Bu Teaching Hospital in Accra, Ghana.

    Our future plans include improving the genetic testing capabilities available at St. Paul’s and launching a genetic counselling training curriculum at the hospital. This focus on patient and health care provider education is vital when introducing a new medical technology, such as genetic testing, into a country or region.

    The Conversation

    This work was funded by grants from the University of Michigan Department of Pediatrics including the Intramural Research Funding Program (Benz Birth Defects Research Award) and the Percy and Mary Murphy Children’s Research Fund.


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    Traditional medicines on sale in Kibera slum in Nairobi.Flickr

    Over 70% of Kenyans rely on traditional healers as their primary source of health care. This number is high because healers respond to diverse needs – they work as herbalists, birth attendants and spiritualists and they’re within reach of ordinary citizens.

    Some estimates suggest that there is one healer for every 950 patients, compared with one doctor for every 33,000 in Kenya. Traditional healers work in both rural and urban settings. And their treatments fill gaps in the official health system.

    Healers also enjoy legitimacy and authority, particularly in villages. They are also custodians of precious biodiversity and the bearers of traditional knowledge.

    For decades little attention was paid to traditional medicine. The colonial power tolerated it as long as healers stuck to their own ethnic group and used traditional methods exclusively. But since independence traditional medicine has increasingly drawn the attention of law makers, regulators and international agencies.

    Today, in the larger towns and cities, healers complement or compete with biomedicine, rather than substitute it. Some operate commercial clinics with their own staff, production systems and internet presence. Others retail remedies on the kerbside or advertise in newspapers and on lampposts offering cures for physical, sexual and emotional complaints.

    In a recently published paper, I look at the steps that have been taken in Kenya to integrate traditional medicine into the country’s healthcare system and to protect community and national interests in traditional medical knowledge. I identify the shortcomings in policies that have been put in place and what’s missing, particularly when it comes to regulating practitioners and intellectual property.

    Evolving approach

    Early independence governments prioritised western biomedicine, as pointed out by historian Kenneth Ombongi in his chapter in The Anthropology and History of Medical Research in Africa.

    In 1969 Kenya’s first president Jomo Kenyatta dismissed healers as charlatans, while health officials called for them to be outlawed, wrote historian John Iliffe in his book East African Doctors: a History of the Modern Profession.

    This changed in the mid-1970s. The shift was influenced by the World Health Organisation’s drive to promote accessible primary care by integrating traditional medicine into the state system. This had already been done in China, Vietnam and Korea.

    In Kenya a dedicated traditional medical research unit was opened at the Kenya Medical Research Institute (KEMRI). But, unlike other African countries such as Ghana, Tanzania and Zimbabwe, plans to professionalise traditional medicine came to nothing.

    In the last two decades this neglect has been replaced by renewed focus and a raft of policies and legislative changes. In my paper, I argue that these changes have focused on two aspects of traditional medicine: practice and knowledge. While the renewed attention is welcome, the outcome on neither front has been totally satisfactory.

    The problem with policies

    Recent health policies have been geared to meeting the state’s constitutional obligation to ensure adequate and safe healthcare. Officials recognised that access could be improved, in part, by harnessing healers, but only where quality can be assured.

    The problem is that there’s insufficient regulation. The National Policy on Traditional Medicine and Medicinal Plants has noted that the optimal dosage of herbal remedies is often unclear because they’re usually stored badly. In addition, many healers treat patients in parallel with ongoing biomedical procedures. This increases the risk of complications setting in. And finally, so-called quacks mislead vulnerable and desperate patients.

    The agreed response is greater legal involvement by enforcing detailed standards and controls and applying the framework for licensing and disciplining healers included in the Health Act passed in 2017.

    The results so far may have been patchy. But the long-term ambition is clear: to standardise and modernise traditional practice.

    Intellectual property

    Kenya, like many other developing countries, has suffered from the appropriation of valuable medical know-how and materials by foreign companies. Documented cases of biopiracy, in Kenya and elsewhere in Africa, are attributed to weaknesses and asymmetries in standard intellectual property law, now enforced by the World Trade Organisation. These tend to favour countries of the global north and companies based there.

    Groups at KEMRI and the ministry of culture are working on how Kenya can develop an export-focused natural products industry.

    Having the proper laws in place is also important. Progress has already been made on this front. In 2016 the Traditional Knowledge and Cultural Expressions Act was passed. The first of its kind in the world, it created a new type of intellectual property right that allows communities to control access to their resources and to profit from them.

    These are early days for the Act which also gives the government significant powers that could trump those of communities. So it’s not clear yet whether national or local development will have priority in the use of these resources.

    New challenges

    Traditional medicine in Kenya has proved resilient. It has withstood state neglect as well as the hostility of medical professionals. It has survived the loss of essential forest resources as well as the incursion of foreign interests. It has adapted and extended its popularity in an urbanising Kenya.

    But the recent turn to recognition and regulation presents new challenges. Problems of patient safety and bogus practitioners, of vulnerable and unexploited indigenous medical knowledge, all have a ring of truth about them.

    The push towards health-for-all and respect for indigenous culture are the popular inheritance of anti-colonial struggles. But the realisation of these values, by addressing the problems, requires deliberation and sensitivity, an acceptance that there will be trade-offs, and a willingness to revise in the light of experience.

    The Conversation

    John Harrington does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.


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    Herbalists mostly recommend treating underlying physiological condition through herbal remediesUNAMID/Flickr

    The use of non-biomedical methods to treat mental disorders in developing countries, like Ghana, has long been acknowledged. The World Health Organisation (WHO) estimates that about 80% of people who need mental health care in developing countries go to indigenous or faith healers for care.

    Some studies have been done to explain the popular use of non-biomedical health care alternatives, and various reasons have been suggested. These include an alignment of the illness beliefs of patients and healers, easier or more flexible accessibility, and cost.

    But many of these studies of non-biomedical health care systems in Africa tend to assess the healers as one homogeneous group of practitioners. In our study, we argued that different types of healers may hold different worldviews. These in turn influence how they conceptualise or think about different disorders.

    We conducted interviews with 36 participants from four different categories of non-biomedical healers in Ghana’s capital Accra. The categories of healers were herbalists, Pentecostal Christian faith healers, traditional medicine men (also called shrine priests) and Muslim clerics/healers.

    Using case vignettes, we examined the healers’ notions about three different types of mental disorders – schizophrenia, depression and post-traumatic stress disorder (PTSD). We examined their ideas about the nature and perceived effects of the different disorders, as well as their thoughts on the causes.

    Understanding the different beliefs about different disorders is important in efforts to improve mental health care in developing countries. In particular, with increased calls for collaboration between biomedical and non-biomedical health care systems, it’s important to understand how the different groups of healers think about different conditions.

    Different views on different conditions

    Our data suggest that indigenous and faith healers’ views on psychotic illness were similar to biomedical notions. But they held different views on depression and PTSD. These views were fluid, and obviously influenced the choice of treatments they offered patients.

    All the healers readily identified the case vignette of schizophrenia as an example of mental disorder. This was often described as “madness” by the healers. Some local names that the healers used included “abɔdam”, “εdam” and “sεkε”. These names are often used to describe people whose behaviour is perceived as disruptive, disorganised or overtly dysfunctional.

    Although the participants believed spiritual factors like witchcraft and curses could cause such a condition, they were also aware that certain physiological processes (such as traumatic brain injury) as well as abuse of drugs and alcohol could account for it. They all considered it to be a severe condition which required urgent intervention.

    So for this psychotic disorder there weren’t major differences in the views of the various categories of healers, and their views were similar to biomedical understanding of psychotic disorders.

    But this wasn’t the case for all the disorders.

    For example, most of the healers were quite firm in their views that post-traumatic stress disorder was not a mental disorder. Rather, they considered it to be a normal reaction to a traumatic experience. The healers thus endorsed more psychosocial explanations for PTSD.

    Depending on their orientation, they described different causes for the symptoms of PTSD. For example, pastors, described PTSD as being due to the presence of a “spirit of fear”. Some herbalists also believed the symptoms were physiological manifestations of “thinking too much”.

    Given these different notions of cause, their recommended treatments also varied. However, all the participants emphasised the need for some form of counselling. In most cases, the healers believed that PTSD could develop into full-blown “madness” (ie disruptive/psychotic behaviours) if left untreated.

    There was a great deal of difference between the healers when it came to depression. Most of the herbalists had physiological explanations for the symptoms and did not consider depression to be a mental disorder. For their part, the traditional medicine men viewed depression as a milder form of mental illness. Some pastors did identify the condition as depression, while the Muslim clerics saw it as potentially resulting from Jinn possession.

    As expected, the recommended treatments were based on the identified cause. For instance, the herbalists mostly recommended treating the underlying physiological condition through herbal remedies. The pastors advocated biomedical care as well as spiritual interventions like prayer and fasting.

    Collaborating

    In many African countries traditional and faith healers are viewed as community leaders and their views are likely to reflect those of their patients. Consequently, biomedical professionals who treat patients who are also seeking help from indigenous and faith healers, would benefit from understanding the different beliefs about different disorders. This can then form an important part of clinical training and practice.

    In addition to this, the healers’ positions of influence within their communities is a unique opportunity to enhance the reintegration and monitoring of patients once they return to their communities. Their influence can also play a key role in fostering patient behaviour change and treatment compliance, as well as eliminating stigma.

    But this can be done only through appropriate collaboration with community-based healers. It can only work effectively if there’s an appreciation of the different views of different healers. Understanding this diversity of approach may be crucial in developing a framework for collaboration amongst different types of healers (including biomedical practitioners) to improve mental health care.

    The Conversation

    Leslie Swartz receives funding from the National Research Foundation.

    Lily Kpobi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.


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    A small hospital in Wakiso district in the central region of Uganda.Shutterstock

    Nearly half of all deaths and about a third of disabilities in low and middle-income countries could be avoided if people had access to emergency care. In Africa the main causes of emergencies are road accidents, obstetric complications, severe illnesses and non-communicable diseases.

    Over the past 18 years the African Federation for Emergency Medicine, an advocacy group, has been encouraging the development of emergency care systems on the continent. The gaps it has identified include decent transport and hospital services.

    But to address these challenges data is needed on the number of hospitals, their locations as well as the population marginalised. Most countries in Africa don’t have this information. They lack basic inventories of health care service providers, including the number of hospitals.

    Our study set out to address this problem by producing the first ever assessment of hospital services in sub-Saharan Africa, and used it to work out peoples’ access to care.

    The results – including how long it takes to get to a hospital – show where investment is needed in improving access. Various interventions are necessary. These should include building new hospitals, improving ambulatory care, building new roads and fixing existing ones.

    But the most urgent action is that countries must update their hospital lists, including assessment of capacity and capability to provide emergency care and updating of the private sector. Our research goes someway to helping them start this process. We have built a database which can be accessed for free and used for assessing service availability at national levels.

    Building the database

    The hospital list covers 48 countries and islands of sub-Saharan Africa.

    To develop the list we used numerous sources for the data, including ministries of health, health information systems, national and international organisations from all the countries and islands. In most cases, the sources were available online but we also relied on personal contacts to obtain hospital data in some countries.

    Close to 50% of the hospitals on the list didn’t have GPS coordinates that could aid in precisely locating them. To overcome the problem we assigned them unique location attributes using online mapping tools such as Google earth and OpenStreetMaps.

    This audit located 4908 public sector hospitals which were precisely assigned location attributes (Figure 1).

    Map of public hospitals in Africa.Author supplied

    Nigeria, which accounts for close to a fifth of sub-Saharan Africa’s population had the highest number of hospitals at 879. Other countries with significantly high numbers of public hospitals were the Democratic Republic of Congo (435), Kenya (399) and South Africa (337).

    The least were in smaller countries such as Cape Verde, Zanzibar, and São Tomé and Príncipe. This information was used as a starting point to calculate the geographic access to the hospital services.

    Timely access

    We measured geographic accessibility by travel time to the nearest public hospital. We did this by calculating how long it would take to travel by road based on the major means of transport in the region.

    We assembled road networks from Google earth and OpenStreetMaps, and assigned travel speeds along the roads. We then developed a model that calculates the time it would take for a patient to travel from any 100m by 100m square grid of location to the nearest hospital.

    More specifically, a significant proportion of women need access to hospital care when in labour and we additionally determined how long they would take to get to the nearest hospital.

    Results reveal that, less than a third (29%) of the total population and 28% of the women of child bearing age, lived more than two hours from the nearest hospitals. The two-hour threshold is a widely used recommendation by the WHO and the Lancet Commission for global surgery for defining access to emergency obstetric and surgical care respectively. In addition, international benchmarks by the Lancet commission for global surgery recommends having 80% of any given population within two hours as critical in ensuring universal health coverage by 2030.

    The most surprising outcome was the huge differences between countries. For example, more than 75% of the population in South Sudan lived outside the two-hour threshold. Other poorly served countries included Central African Republic, Chad and Eritrea. More than half of their populations lived outside the two-hour threshold.

    The best served countries were mostly islands like Zanzibar, Comoros and São Tomé and Príncipe. More than 95% of their populations were within two hours of a hospital. Large countries such as Kenya, South Africa and Nigeria also had good access indices, with more than 90% within the two-hour band.

    All 48 countries in our survey have signed up to the sustainable development goal of delivering universal health care by 2030, part of which involves access to hospitals. Our research can help countries work out what they need to do to make this a reality when it comes to emergency care. There’s still a long way to go. Only 16 countries in our survey achieved 80% coverage in access to a hospital within two hours.

    The Conversation

    Paul Ouma receives funding from the Initiative to Develop African Research Leaders as a PhD student (# 107769). The work was also supported by Wellcome Trust Principal Fellowship to Robert W Snow (# 103602) and the Department for International Development (UK) – Project on Strengthening the Use of Data for Malaria Decision Making in Africa (DFID Programme Code # 203155). The authors also acknowledge the support of the Wellcome Trust for the Kenya Major Overseas Programme (# 203077).

    Emelda Okiro receives funding from the Wellcome Trust as an intermediate research fellow (# 201866).


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    Foreign spaza shop owners are being accused of selling "fake" food. Shutterstock

    Owners of small shops in South Africa – in most cases foreigners – have been accused of stocking counterfeit food and food that’s past its sell-by date. The issue has been caught up in xenophobic violence, with shop owners targeted by South Africans . There is very little hard data about what’s referred to as “fake food” in both the formal and informal sectors. This means the issue is politically charged and dominated by opinions, not evidence. The Conversation Africa’s Ina Skosana asked Jane Battersby-Lennard and Gareth Haysom to unpack this issue.

    What is counterfeit food?

    There are many different kinds of counterfeiting. Not all pose a risk to consumers, though some clearly do. Counterfeit doesn’t necessarily mean unsafe, and consumers aren’t necessarily unaware of counterfeiting. They may in fact choose these goods for cost or convenience reasons.

    Counterfeit foods that don’t pose a risk include what are called “diverted products”. These goods are only licensed to be sold in one place or in one format but are sold elsewhere. This could include multipack items sold individually, free promotion goods being sold, or supermarket brand items being sold outside a supermarket. They could be over-runs from factories, or goods taken from food producers by employees and sold on.

    Counterfeit foods that pose more of a problem include simulations – goods made to replicate branded items. They often use cheaper ingredients and can have health risks. Another risky area is tampered food: products that have been adulterated by adding materials to bulk them out, or foods that have been re-worked to refresh them after expiration dates. A South African chicken company was accused of doing this seven years ago.

    There are also troubling, yet seemingly spurious allegations, that food has been contaminated with non-food items like plastic. The Minister of Health, Aaron Motsoaledi, has stated that the department hasn’t received any evidence of this, or notifications of people becoming ill as a result.

    How big a problem is counterfeit food in South Africa?

    We just don’t know how extensive the different kinds of counterfeiting are. It is clearly present in both formal and informal sectors of the food system. The general consensus is that it’s increasing.

    There is an important difference between how extensive counterfeit food’s presence is and how big a problem is it. Who is it a problem for? If we are thinking about problems for health, it is important to note that the largest food borne disease crisis South Africa has had – listeriosis– was traced back to non-counterfeit food from a large company.

    How big a problem is the sale of expired food?

    In South Africa perishable foods have to have an expiration date after which they can’t be sold or donated. Non-perishables – foods with a stable shelf life – have best before dates. These are for quality, not safety, and foods can legally be sold after these dates. Many people buy these products as they get them at discounted rates.

    The danger is when expiration dates are tampered with and consumers are illegally sold expired food, or if best before dates are tampered with and consumers lose the ability to make their own quality judgements.

    But different kinds of counterfeiting of different kinds of food have different potential health outcomes. Expired foods can cause serious illness, even death but expiration dates on foods are generally conservative to protect companies from liability. Some foods may well still be safe after their expiration date.

    Foods outside of their best before date, especially non-perishables, have far less risk.

    From a business point of view, counterfeit foods can pose a threat to the owners of companies that make legitimate products.

    What’s missing in the debate?

    A lot. The “blame” for counterfeit food currently seems to be squarely at the feet of “foreigners” – both vendors and the alleged “cartels” supplying them. These allegations have serious consequences. Government has initiated “blitzes” on foreign-owned shops, seized goods and shut down businesses. Some communities have turned to looting shops and inciting xenophobic violence.

    However, counterfeiting exists for many reasons. These need to be considered in the debates about ‘fake’ foods.

    Firstly, counterfeiting is difficult to control because of the globalisation of supply chains combined with weak national and international enforcement of trade regulations.

    Secondly, regulations are poorly enforced at the local level, as evidenced by the failure of environmental health in the listeria outbreak. On the one hand technological innovations are making it cheaper to produce counterfeit foods or replica labels. On the other hand, there’s consumer complicity: people want cheap goods.

    Thirdly, there’s the issue of market dominance and the barriers to entry for legitimate businesses that produce “off brand” items. To what extent are large, formal retailers being protected against market entry by smaller players? How then do smaller suppliers enter the market?

    What needs to be done?

    The solution to concerns about food safety from counterfeit foods isn’t to confiscate goods from foreign traders, criminalise shop owners and close their shops. These steps seem to be driven by political, rather than health, motives.

    Rather, the first step should be to make sure better data is gathered on the extent of the sale of counterfeit foods – recognising the diversity of kinds of counterfeiting and assessing the relative health risks.

    There is also a need to understand why counterfeit goods appear on the market and to address the root causes. These may include a commitment to greater transparency at border control; and redoubling commitment to training environmental health officers in municipalities so that they can actually conduct food testing from both formal and informal retailers and producers.

    It’s also important to address barriers to entry for smaller producers who want to enter the market legally but are excluded. And, ultimately, South Africa must address food insecurity and poverty. These are the main drivers of consumer demand for cheap foods.

    Etai Even-Zahav, a researcher at the Sustainability Institute at Stellenbosch, contributed to this article

    The Conversation

    Jane Battersby receives funding from the International Development Research Centre, and the Economic and Social Research Council and Department for International Development. She is currently a Fulbright Scholar-in-Residence at Dickinson College, Pennsylvania. Jane Battersby is also a member of the Independent Expert Group of the Global Nutrition Report.

    Gareth Haysom receives funding from the International Development Research Centre (IDRC) under the International Partnerships for Sustainable Societies (IPaSS) Program and Economic and Social Research Council (UK) and the UK Department for International Development.


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    Climate change also has an impact on public health.Shutterstock

    Half a century ago concerns about climate change, environment vulnerability, population density and the sustainability of earth systems reached a broad audience. This was clear from books like the Silent Spring published in 1962, and The Limits to Growth published 10 years later.

    These works influenced environmental activism at the time. They also laid the foundations for growing scientificevidencethat climate change was happening and was negatively affecting the earth.

    But one piece of the puzzle has been missing: the impact of climate change on people, and specifically, on public health.

    This changed at the beginning of this century with growing advocacy and gatherings such as the Conference of Parties and the publication of new research. Scientists began writing about the earth moving into a new era called the Anthropocene. This is an era in which ecosystems were increasingly being affected by human behaviour, and in which people were being affected by the changes brought about by their actions.

    The Anthropocene provided the impetus for renewed attention on health and sustainability for all species. This new understanding led to increasing new research, across disciplines, to new interdisciplinary journals, and to policy documents on the impact of climate change on health. Major new insights began to emerge. These included the fact that changes in weather patterns were affecting the behaviour of mosquitoes. This in turn was affecting our ability to control disease. A raft of work also started to emerge on the affects of changing weather patterns, heat waves, and access to clean water on people’s health.

    The next step along this journey was that academics came to realise that they can’t work in disciplinary silos. For example, health scientists came to grasp that they need anthropologists, sociologists and economists for a full understanding of the impact of climate change. The circle of knowledge has, as a result, begun to expand.

    Parallel to these efforts, artists and advocacy groups have worked to keep climate change on international and national policy agendas. For example, artists have taken inspiration and drawn from scientific research in engineering, chemistry, biology, and the earth sciences to make their art. In a first of its kind on the African continent, these efforts are reflected at a 10-day public and academic programme at the University of the Witwatersrand. The programme enmeshes art and science to provoke new thinking about water and how its politicisation affects public health.

    Insights from different disciplines

    Extreme weather events, shifts in temperature variation and precipitation, and higher mean temperatures have dramatically affected human health and well-being.

    From a health perspective, incremental environmental changes over time have undone decades of investment in the control of infectious diseases. Many of these are water-borne and water-washed diseases, such as dysentery and scabies. They are result of poor personal hygiene because of inadequate water availability. These diseases, common throughout Africa, are often described as neglected diseases of poverty.

    Scientists have started to explore the various affects in different settings in relation to different diseases.

    For example, changes in temperature and rainfall have, in turn, changed the behaviour of vectors such as mosquitoes, flies and snails, with other factors complicating the spread of disease (for a summary, see). This means the settings that create the conditions for debilitating and potentially fatal diseases such as malaria, zika, and dengue have shifted. For example, mosquitoes have moved to new areas, introducing infection to previously unaffected people and certain animals.

    Anthropologists have used a different lens to understand the impact. Research shows that inequality influences people’s exposure to vector-borne diseases and other environmentally sensitive infections. Gender, class and age have also emerged as points of vulnerability for disease and poor health in the context of climate change.

    Climate change has, most notably, begun to affect weather patterns. Changes in precipitation and quantity, floods and droughts, and water insecurity are increasingly common as the planet warms.

    Scientists have begun to track how this affects food production and other farming activities. This in turn affects people’s livelihoods and food security. These changes are increasingly being followed not just by climate scientists, but also by academics from disciplines as wide-ranging as economics and politics. This follows the realisation that challenges of ageing infrastructure and water governance, for example, complicate finding solutions to overcoming the challenges posed by global warming.

    Creative interventions

    Scientists across disciplines – social, biological, and physical sciences as well as the humanities and arts – need to continue to work on ways to interrupt disease transmission in the context of global warming. They seek to identify appropriate interventions where climate change affects health – and to come up with creative solutions that cut across narrow paths of thinking.

    Artists and civil society have a key role to play by creating narrative, visual and acoustic forms to support advocacy on issues of climate change, pollution, the ecology and environmental justice.

    The Conversation

    Lenore Manderson has received research funding from the Australian Research Council and more recently, the South African National Research Foundation. She has been an advisor to Special Programme for Research and Training in Tropical Diseases (TDR) for the past 30 years.


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    It's projected that Africa's population will double by 2050.Shutterstock

    I think about the future of my continent in terms of three questions: Are Africans healthy? Do they have access to a good education? And do they have opportunities to apply their skills?

    Millions more Africans have been able to answer yes to these questions in recent years. But there’s an elephant in the room. One of the keys to keeping this progress going is slowing down the rapid rates of population growth in parts of the continent. But population issues are so difficult to talk about that the development community has been ignoring them for years.

    Population growth is a controversial topic because, in the not-too-distant past, some countries tried to control population growth with abusive, coercive policies, including forced sterilization. Now, human rights are again at the centre of the discussion about family planning, where they belong. But as part of repairing the wounds created by this history, population was removed from the development vocabulary altogether.

    For the sake of Africa’s future, we should bring it back. Based on current trends, Africa as a whole is projected to double in size by 2050. Between 2050 and 2100, according to the United Nations, it could almost double again. In that case, the continent would have to quadruple its efforts just to maintain the current level of investment in health and education, which is too low already.

    But if the rate of population growth slows down there will be more resources to invest in each African’s health, education, and opportunity – in other words, in a good life.

    To be very clear: the goal of family planning programmes is not to hit population targets; on the contrary, it’s to empower women so that they can exercise their fundamental right to choose the number of children they will have, when, and with whom. Fortunately, empowering couples to make decisions about their lives also improves Africa’s future by changing the population growth scenario across the continent.

    Scenarios

    Some relatively simple future scenarios for sub-Saharan Africa have been modelled to consider how various family planning-related investments might affect population growth. These have been built using data from the Track20 Project. The project monitors global progress in extending access to modern contraceptives to additional 120 million women in the world’s 69 poorest countries by 2020.

    Let’s examine the data.

    How different investments in family planning may affect the African population.2018 Goalkeepers data report

    Wanted fertility: the black line represents sub-Saharan Africa’s population to 2100 based on estimates by the United Nations Population Division. The blue line represents its population to 2100 if every woman had only the number of children she wanted. Currently, women in the region have an average of 0.7 more children than they want. If that number went down to zero over the next five years, the population in 2100 could change by 30%.

    Education: another link between empowerment and population growth is the transformative impact of secondary education for girls. Educated girls tend to work more, earn more, expand their horizons, marry and start having children later, have fewer children, and invest more in each child. Their children, in turn, tend to follow similar patterns, so the effect of graduating one girl sustains itself for generations. Though the impact of education is sweeping, our model looks at just one narrow aspect of it: a shift in the age at which women give birth to their first child.

    The pink line represents sub-Saharan Africa’s population if every woman’s first birth were delayed by an average of approximately two years. The average age at first birth for women in Africa is significantly lower than in any other region. Currently, it is 20 or younger in half of African countries. This scenario doesn’t have anything to do with women having fewer children. It just has to do with when they start having them.

    Consider this thought experiment. If every woman started having children at age 15, then in 60 years you’d have four generations (60/15=4). But if every woman started having children at age 20, then in 60 years you’d have three generations (60/20=3). Even if those women had the same number of children in each generation, the total population would be one-quarter smaller in the latter scenario. To be conservative, we assumed a less substantial delay in our model. Still, it changes the projected population by nearly 10%.

    All well-meaning Africans will support sending girls to school and giving them access to information about family planning and contraceptives when they ask for them.

    And I hope we will stop shying away from also pointing out that empowered women make millions of individual decisions that add up to a better demographic situation for themselves, for their children, and for Africa.

    A version of this article was first published in the Goalkeepers Report

    The Conversation

    Alex Ezeh does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.


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    Girls in Kenya face a range of challenges.Shutterstock/Adriana Mahdalova

    Adolescent girls in Kenya face a range of challenges that compromise their ability to learn, earn and thrive. Girls who live in cash-poor environments are at risk of dropping out of school, sexual violence and early sexual initiation, early and unintended pregnancy, and early marriage.

    It’s critical to intervene before events like this take place. An initiative in two marginalised areas of Kenya – the country’s largest slum Kibera in Nairobi and Wajir County in Northeastern Kenya – is attempting do just that through a combination of interventions intended to empower girls and keep them safe.

    The initiative, called the Adolescent Girls Initiative - Kenya, began in 2014 and reached 6,000 girls aged 11-15. It involved the Population Council and African Population and Health Research Center. Save the Children and Plan International implemented the program in Wajir and Kibera.

    It tested the effects and measured the financial costs of various interventions – from violence prevention and economic empowerment to health and education. The evidence emerging from the study is encouraging. Results show that positive changes for adolescent girls are possible in these two very different, marginalised settings. And it reinforces the point that context matters, and that interventions must be tailored to different settings.

    The interventions

    The project involved four interventions —- violence prevention, education, health and wealth creation —- aimed at addressing particular problems. Each was designed to deal with the particular circumstances of communities.

    Violence Prevention: Groups of adult stakeholders participated in community dialogues on the challenges facing girls in their community. They were then given funding to develop and implement a plan to address at least one of those challenges.

    In Wajir, for example, most of the challenges identified related to girls not enrolling in or dropping out of school and the communities wanted to improve the poor infrastructure in the schools. Therefore, most of the projects involved building classrooms, latrines, or pipe water into the schools.

    In Kibera, the group created libraries or resource centres to respond to the girls’ need for a safe place to do homework.

    Education: A cash transfer, conditional on school enrolment at the start of each term and regular attendance throughout the term, was made to cover schooling costs. Participating families received a bi-monthly incentive payment ($15 in Wajir; $11 in Kibera), direct payment of a portion of school fees (about $7 per term for primary school and $60 per term for secondary school), and a schooling kit for the girls that included sanitary pads, underwear, soap, a pen and a notebook.

    Health: Weekly girls group meetings – called safe spaces – were held. These were facilitated by a young woman from the community and covered a range of health and life skills topics including sexual and reproductive health.

    Wealth Creation: Financial education was provided in group meetings. In addition, savings accounts were opened in the urban site and home banks distributed in the rural site. A small amount (USD$3 per year) was also given as an incentive to save.

    What worked

    At the end of the two year programme, the project’s results show positive impact for girls across a broad range of health, social, educational, and financial indicators in both Kibera and Wajir, though results varied across both sites.

    Education: The effects of the conditional cash transfers were positive. The point of impact depended on context. In Kibera, where enrolment in primary school was already close to 100%, cash transfers improved completion of primary school and transition to secondary school. But in Wajir, where only 75% of girls were enrolled in school at baseline, cash transfers served to increase primary school enrolment to 95%. This was a huge improvement clearly demonstrating the power of education cash transfers to bolster school enrolment in under-resourced and marginalised communities.

    Health: The health intervention results were also different in the two regions. In Kibera, girls participating in the safe spaces groups were more likely to have improved knowledge, seek help and know how to use a condom and have social safety nets. Girls who actively participated in the safe spaces groups were also more likely to stay in, or complete, school.

    But in Wajir, girls participating in safe spaces groups were not likely to know about sexual and reproductive health. This could be due to the socially conservative cultural norms in Wajir. However, participation in groups did lead to small improvements on girls’ belief in more equitable gender norms and self-efficacy, or a girl’s belief about her ability to succeed in a given scenario.

    Wealth Creation: Financial literacy and savings improved in both regions. At baseline, less than 1% of girls reported having savings. For girls who received all four interventions (health, education, violence prevention, and wealth creation), the number rose to 42%. The combination of financial education sessions with savings mechanisms and $3 incentives confirms that having the opportunity to immediately put into practice the new skills helps the theoretical training to “stick.”

    Violence Prevention: All groups received violence prevention, therefore, it was not possible to evaluate its community-based impact. However, researchers concluded that conversations on gender inequalities, education cash transfers and safe spaces in Wajir laid the groundwork for a shift in thinking about girls in the community. For example, after the intervention, community members increased their expectations that girls would complete secondary school and increased the age at which families expect girls to get married.

    What’s next

    Evidence from the project reinforces the theory that helping adolescent girls build social, health, education and economic assets through a multi-sectoral approach, involving communities and households, is more cost effective than any one singular intervention component – and leads to a larger impact and positive change on girls’ lives.

    The design of future interventions for vulnerable girls needs to account for the context to maximise efficiency of spending resources –- particularly on education cash transfer programs.

    An end line survey, will be conducted in mid-2019 to confirm if improvements in social, health, savings, and educational attainment for girls in the medium term will have a longer term influence on the timing and choices of marriage and sexual relationships. These results are expected in 2020.

    The Conversation

    Karen Austrian works for Population Council. She has led Population Council grants from the UK Department of International Development which funded AGI-K.


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    Conditions in Kenya's slums like Mathare are not conducive to healthy life choices.EPA/Daniel Irungu

    Africa is experiencing a demographic and nutrition transition. More and more people are moving to urban areas. Slum communities currently constitute about 56% of the urban population in sub-Saharan Africa. That’s more than 200 million people, more than the entire population of Nigeria.

    Even as under-nutrition or not getting enough calories and nutrients – continues to be a problem particularly among the poorest, overweight and obesity are growing challenges in poor urban areas. Being over a healthy weight invites a host of non-communicable diseases.

    Recent research suggests that rapid increases in obesity are a result of complex interactions between factors such as people eating higher-calorie diets and engaging in lower levels of physical activity. Genetic and environmental factors also play a role.

    Our research set out to establish the relationship between obesity and income levels in poor urban areas.

    Previous research has established wealth as a potential risk factor. But there have been questions about exactly what the link is, and whether income and obesity levels are linked even in urban slums where all incomes are very low, yet there is some variation in socio-economic status.

    We set out to investigate the relationship further. Our aim was to gain insights that would inform strategies to manage obesity in Kenya’s poor urban areas.

    Our research found that there was an association between relatively higher economic status and levels of obesity in a slum setting. The study suggests that obesity levels are higher in the higher economic brackets – and particularly among women.

    The research

    The study was done in two Nairobi slums, Korogocho and Viwandani. Data was collected between 2014 and 2015. More than 2,000 adults between 40 and 60 years of age were included in the study. Data on weight, height, and basic socio-economic variables were collected by experienced and trained field workers.

    We examined the association between a measure of socio-economic status – calculated by combining information on living conditions and household assets – and body mass index which is used as a measure of obesity.

    We found that one fifth of our study population was obese. And nearly six times more women were obese than men – 32.2% compared to 5.6%.

    We found a strong association between body mass index and socio-economic status. Women higher up the economic ladder were more likely to be overweight. The association was higher for women than for men.

    Interventions

    The findings support the idea that economic status could potentially be used as a predictor of overweight and obesity in slum settings though this would need further exploration. Such predictors could prove useful for rapid assessments of health and socio-economic status in slum populations.

    But policymakers must strike a careful balance. As incomes increase among the very poor, body mass index increases – which is good for those who are underweight. But for those who are already a healthy weight, increasing incomes mean slum dwellers have a higher likelihood of becoming overweight or obese.

    Women are particularly at risk. This could mean that much needed socio-economic development in urban slums could also usher in unintended increases in overweight and obesity, putting slum dwellers at increased risk of non-communicable diseases – even as they continue to face threats from communicable diseases common to areas with poor water and sanitation facilities.

    Because of this, interventions that aim to improve the socio-economic status of individuals in urban slums should, as a starting point, integrate health promotion programmes targeted at prevention of obesity. Future policies targeting the health of slum populations should prioritise interventions for overweight and obesity among higher income groups, and underweight for the poorest.

    The Conversation

    The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.


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    Researchers have raised concerns about anti-fungal resistance.Shutterstock

    When most healthy people think of fungal diseases, they often think of oral or vaginal thrush, nappy rash, fungal nail infections, and athlete’s foot. Although these are very common, annoying and sometimes debilitating conditions, they can be treated.

    But some fungal diseases can be extremely serious and, particularly for those with compromised immune systems, even life threatening. People living with HIV; cancer patients; people who are admitted to hospital; people who are critically ill after trauma or surgery; and premature babies are among those most at risk.

    The advocacy group Global Action Fund for Fungal Infections estimates that fungal diseases cause between 1.5 million and 2 million deaths every year. Many of these occur among people with AIDS or among those who develop fungal sepsis in hospital.

    Anti-fungal resistance is also a problem. People with serious infections caused by fungi that are resistant to the first-line or even second-line of anti-fungal treatment have a greater chance of dying than those infected by fungi that are susceptible. Over the last 10 years, a multi-drug resistant fungus called Candida auris has spread across the world and caused large outbreaks in hospitals. In South Africa, cases of Candida auris have been diagnosed at almost 100 hospitals.

    One of the biggest concerns around life-threatening fungal diseases is that they cause a largely silent epidemic. These diseases are usually diagnosed among sick people, so healthy people are not always aware of these infections unless they or their close relatives become ill. Another concern is that doctors may not consider fungal diseases when they see ill patients.

    For example, researchers have recently found that invasive aspergillosis affects almost one in five people with severe influenza admitted to intensive care units. This deadly fungal infection usually affects the lungs of people being treated for cancer. It’s the most common missed infectious cause of death in intensive care.

    Some fungal diseases are very difficult to diagnose because the available laboratory tests don’t pick up all true cases of disease, laboratory tests are not available or because fungal diseases can be mistaken for tuberculosis.

    Global efforts to control fungal diseases

    But health authorities across the world are starting to pay closer attention to life-threatening fungal diseases. For instance, the World Health Organization has recently decided to monitor anti-fungal resistance using its global surveillance system. In 2018, it issued new guidelines to prevent and manage cryptococcal meningitis.

    Few African countries have a comprehensive approach to reducing deaths or disabilities caused by fungal infections. In South Africa, there are several measures to deal with life-threatening fungal diseases. The department of health provides guidance to health care workers on how to diagnose and treat people living with HIV who have serious fungal diseases.

    The country’s National Institute for Communicable Diseases monitors trends in certain serious fungal diseases and provides technical assistance to investigate and respond to outbreaks. This involves conducting field investigations to confirm an outbreak, as well as collecting samples from patients and the environment for laboratory testing.

    South Africa’s Essential Medicines List also recognises the severity of these diseases – it includes important medicines needed for treatment of fungal infections in communities and hospitals. But some life-saving anti-fungal medicines are still not available for treatment because they are not registered by the South African Health Products Regulatory Authority or are too costly.

    The National Health Laboratory Service automatically screens people with HIV who have a CD4 count <100 cells/mcl for cryptococcal antigen. A CD4 count measures the strength of the immune system. The lower the count, the weaker the immune system.

    Cryptococcal antigen is a part of the fungus that appears in the blood with disease. People whose blood screens positive for cryptococcal antigen are considered to have active cryptococcal disease. They are then offered immediate antifungal treatment, even if they do not feel ill.

    My colleagues and I at the National Institute for Communicable Diseases are trying to work out if this national cryptococcal antigen screen-and-treat programme has reduced deaths from cryptococcal meningitis. While a similar approach reduced deaths by almost 30% in a clinical trial, it’s important to confirm the same impact when the intervention is implemented in routine care.

    To combat serious fungal infections, researchers at various institutions are also testing vaccines, new anti-fungal medicines or combinations of medicines in clinical trials.

    All of this will hopefully lead to more people being diagnosed and treated earlier so that they have a better chance of recovery. But it’s not just up to researchers and health authorities to curb the epidemic. Ordinary people can also play a part.

    Preventing and treating fungal disease

    Most day-to-day exposures to fungi that can make you sick cannot be avoided. That’s because fungi are everywhere in the environment and some are also found on your skin and in your gut as part of your healthy flora.

    But you can try to avoid high-risk exposures if you know that you have a weakened immune system. For example, healthy people who come into contact with soil where there are bat or bird droppings (when exploring caves, cleaning chicken coops or renovating old buildings) can develop a mild flu-like illness called acute pulmonary histoplasmosis. This can get better with, or sometimes without, anti-fungal treatment.

    But people with weakened immune systems who are exposed to the same risks can develop a life-threatening form of this disease which is very difficult to treat.

    If you are diagnosed with a serious fungal disease, ask for its name so that if you get ill again, you can tell your doctor about this. Take your medication as prescribed and finish the course. If you’re admitted to hospital and have a urine catheter or a drip in place, ask every day if you still need the catheter or drip. Removing urine catheters and drips reduces your risk of developing an infection in hospital.

    Finally, people should advocate for hospitals to openly publish their rates of health care associated infections, including fungal infections. This will help in making informed decisions.

    The Conversation

    Nelesh P. Govender receives funding from the South African National Research Foundation, the US National Institutes of Health and the US Centers for Disease Control and Prevention. He is a member of the Cryptococcal Meningitis Action Group, an international advocacy group which aims to reduces deaths associated with cryptococcal meningitis among people living with HIV.


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    Fundamental questions of ethics are involved in donor transplant decisions. Shutterstock

    South Africa has a dire shortage of organ donors. This means that doctors struggle to find suitable donor organs for critically ill patients who would die without receiving a transplant. Sometimes they have to make tough calls such as using a blood group incompatible organ to save a patient’s life – even if this comes with additional risk.

    About a year ago we made a tough call of our own: we could save a child’s life by giving the child a liver transplant– but risked infecting the child with HIV in the process. The donor was the child’s mother, who is HIV positive and the child was HIV negative. The procedure came with a risk of transmitting HIV to the child.

    South Africa’s law does not forbid the transplantation of an organ from a living HIV positive donor to an HIV negative recipient, provided that a robust informed consent process is in place. But this isn’t universally accepted as best clinical practice because of the risk of HIV transmission to the recipient.

    The young recipient had been on the organ donor waiting list for 181 days. The average time on the waiting list in our transplant programme is 49 days. The child’s mother had repeatedly asked if she could donate a part of her liver, but we could not consider this because it was against the policy in our unit at the time. Without a transplant, the child would certainly have died.

    After much consideration, and with permission from the Medical Ethics Committee at Johannesburg’s University of the Witwatersrand, we decided to go ahead with the transplant. With careful planning we were able to give the child antiretroviral drugs in advance, with the hope of preventing HIV infection.

    The transplant, which happened at the University of the Witwatersrand’s Donald Gordon Medical Centre, was a success. The child is thriving, but at this point we are unable to determine the child’s HIV status. In the first month after the transplant we detected HIV antibodies in the child and it looked like HIV infection might have taken place. But as time went by the antibodies declined and are now almost undetectable. We have not been able to work out for certain whether the child has HIV or not. Even with ultra-sensitive, specialised testing, we have not been able to detect any HIV in the child’s blood or cells.

    It will probably still be some time before we can be sure. However, the child is doing very well on antiretroviral treatment. And we know from cases where HIV was transmitted inadvertently that people who get HIV from an organ transplant do as well as those who get an HIV-negative organ.

    This operation could be a game changer for South Africa. The country has a large pool of virally suppressed HIV-positive people who have previously not been considered for living liver donation. Viral suppression is when a person with HIV takes their antiretroviral medication as prescribed and their viral load – the amount of virus in their blood – is so low that it is undetectable.

    Ethical and legal considerations

    Organ transplant comes with many ethical and legal challenges. In this case, some unique and complex issues were carefully considered.

    We took great care to consult widely before doing the transplant. This included speaking to the members of the transplant team, bioethicists, lawyers, experts in the field of HIV medicine and Wits University’s Medical Ethics Committee. The committee’s function is - among other things - to protect patients in medical research, and to make sure doctors are doing procedures for the correct reasons.

    It was clear that a transplant was in the child’s best interests. The bigger ethical question was whether it was right to deny the mother the opportunity to save her child’s life. A fundamental principle of ethics is to treat people fairly. People with HIV should have the same health care options as everyone else.

    We, along with the Ethics Committee, agreed that as long as the child’s parents understood that there was a risk the child could acquire HIV, it was acceptable to go ahead with the transplant.

    Then, to ensure that the child’s parents were properly informed and in the best position to make a decision, we used an independent donor advocate. The advocate was not employed by the hospital and their main role was to support the parents by ensuring that they understood exactly what the risks were for the mother as a donor. The advocate also engaged with the transplant team on the parents’ behalf, if needed.

    In this case, the parents were committed to go ahead with the operation, and had already come to terms with the risk of HIV transmission to their child. They were appreciative that the team were willing to carefully consider this option for them, given that there were no alternatives available and their child was critically ill. We asked both parents to consent to the procedure, as both are responsible for taking care of the child going forward.

    Lessons and opportunities

    This operation has shown that doctors can do this type of transplant, and that outcomes for the HIV positive donor and the recipient can be good. It has also created a unique opportunity for scientists at Wits to study HIV transmission under very controlled circumstances.

    For now, doctors will not be able to tell parents whether or not their child will get HIV from this type of transplant. This is because this is a single case with many unanswered questions that will hopefully be answered through ongoing research.

    Going forward, we will continue to ensure that parents are fully aware of the uncertainty in this situation. All future cases will be part of an ongoing research study that will investigate HIV transmission in children in more detail and the ways in which HIV may or may not be spread through organ transplantation.

    The Conversation

    The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.


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    Parasitic worms live in the soil and water where they can constantly reinfect people. EPA/Jane Hahn

    Deworming has become a common practise across the world. It has proved very successful reducing the burden of parasitic worms among children by more than 50%.

    The success of the last 17 years has been driven by deworming initiatives where school-going children get deworming tablets once to twice a year – and could have been greater if there was a vaccine.

    But parasitic worms – found mainly in tropical and subtropical areas particularly in sub-Saharan Africa, the Americas, China and East Asia – remain a challenge. The World Health Organisation’s latest figures show that across the world, there are close to 1.5 billion people– about one fifth of the world’s population – infected with parasitic worms.

    The persistence of parasitic worms shows that deworming is not enough to interrupt the worms’ transmission. One part of the problem is that they live in the soil and water where they can constantly reinfect people even after they have been treated. Another part of the worm problem is that diagnoses are poorly efficient, anti-worm drugs are limited and tightly overlapping geographics and ecologics render co-infections with other diseases like HIV, malaria or tuberculosis frequent.

    But most importantly, communities are not educated about the dangers. This means that even when they are treated they continue activities that result in them being reinfected.

    The WHO has set a goal to eradicate the burden of parasitic worms in children by 2020. To do this, it’s advocating mass deworming campaigns. But the only way to achieve the 2020 goal is to combine deworming with other tools such as education campaigns.

    We learnt some refreshing lessons in rural Cameroon on how this should be done. Our study looked at a campaign against schistosomiasis – more commonly known as snail fever. Part of the campaign involved educating children, teachers and legal guardians in rural Cameroon about the dangers.

    The data we collected showed that mass drug administration alone had a questionable efficiency in halting schistosomiasis transmission. But that coupling mass drug administration of praziquantel to children with information about risk factors of infection might produce better outcomes. In fact, another recent study in Côte d’Ivoire unequivocally found that repeatedly informing communities how parasitic worms are transmitted and giving them a set of safe practices considerably helped to avoid reinfection.

    This underscores the importance of including - among other complementary measures - extensive population awareness campaigns in the deworming strategies to reduce the burden of these diseases. Such health education ventures that are low-cost clearly constitute a necessary tool for creating the enabling environment for mass drug administration campaigns to thrive.

    The challenges

    There are four main challenges when it comes to managing parasitic worms. All are particularly visible in tropical and sub-tropical countries where sanitatory conditions are insufficient and people’s lifestyles undermine attempts to interrupt the transmission of parasitic worms.

    The first challenge is diagnosis. The diseases caused by parasitic worms are generally asymptomatic. This means that the early signs of infection are usually missed. In cases where people develop severe disease, they usually have symptoms like diarrhoea, abdominal pain, blood loss that can result in anaemia, cognitive deficit and tissue destruction. On rare occasions, these diseases can result in death.

    But because people don’t show symptoms, most do not know that they have the worms in their body until the parasites proliferate.

    The second problem is reinfection. Even after populations receive treatment, they can still be reinfected.

    The third challenge is that there is a limited repertoire of anthelminthic drug therapies. These have been repeatedly administered for decades raising concerns about drug resistance in areas targeted for frequent campaigns.

    And the fourth is the problem of co-infections with major communicable diseases such as HIV, malaria or tuberculosis. In many instances the parasitic infections accelerate the course of these diseases and worsen their burden.

    Tackling the problem

    Creating awareness in communities is critical and arguably the most cost-effective tool in an anti-worm strategy.

    It is important to educate and involve infected people in mass deworming campaigns. There are some examples of success. Kenya, for example, has managed to eradicate Guinea worm disease as a result of deworming campaigns being complemented by health education. Guinea worm disease is caused by Dracunculus medinensis– a long, thread-like worm.

    Educational campaigns should include three vital messages. The first must explain how parasitic worms are spread, the second must explain the importance of sanitation in preventing transmission and the third should stress the limitations of mass drug treatments.

    These campaigns should include messages on how to protect water sources and sanitation and hygiene practices.

    Unless these health awareness campaigns are incorporated into strategies that target parasitic worms, there won’t be much improvement in trying to sustainably reduce the burden of parasitic worms and achieve the elimination rather than the control of these diseases.

    The Conversation

    Justin Komguep Nono receives funding from the National Research Foundation of South Africa, the Merck Global Health Institute, the International Centre for Genetic Engineering and Biotechnology (CRP/CMR15-05) and the European Union via the European & Developing Countries Clinical Trials Partnership (EDCTP2) programme through funds TMA2016CDF-1571

    Hlumani Ndlovu receives funding from Medical Research Council of South Africa (MRC-SA).


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    A girl gets tested for HIV in Uganda where attempts to integrate HIV services with general health service have failed. Shutterstock

    In many countries in sub-Saharan Africa, HIV services are still offered separately within health facilities. These HIV clinics have their own dedicated staff and infrastructure such as waiting areas, a separate patient flow system and they typically run on designated days of the week. This is known as a vertical model and was touted as a pragmatic emergency strategy to overcome sub-Saharan Africa’s weak health systems in the quest to rapidly enrol millions on HIV treatment.

    Vertical HIV clinics are very common in sub-Saharan Africa. Studies conducted in Kenya, Swaziland and Zambia suggest that stand-alone HIV clinics are the rule rather than the exception in the region.

    Stand-alone HIV clinics have depended substantially on donor aid especially from the US’s President’s Emergency Plan for Aids Relief (PEPFAR). But over the past five years, there have been persistent reports of declining international assistance to scale up HIV services in sub-Saharan Africa. This has been one of the main drivers of calls for integrating HIV services with non-HIV services to avoid duplication and promote long-term programme sustainability.

    Numerous studies have been done evaluating the integration of HIV services with other health services such as sexual and reproductive health service or those for non-communicable diseases. In addition, several policies, including World Health Organisation guidelines, have outlined ways in which HIV services can be integrated into general health services.

    But, research we conducted across eight geographic sub-regions in Uganda shows that the country is not prepared for this integration. This is because general clinic staff don’t have specialist HIV knowledge, as well as the fact that sheer numbers of HIV clients will make it difficult. We argue that a more nuanced approach should be taken.

    Why not

    Our study identified a number of potential challenges in doing away with stand-alone HIV clinics.

    Firstly, we found that HIV-related stigma was widespread among health workers. For example, we found that some health workers in the labour ward of a public health centre refused to touch HIV positive expectant women.

    Secondly, we found that HIV-positive patients were discriminated against. In one large hospital we visited, the pharmacy prioritised patients who paid for their medication while HIV patients were treated last because they don’t pay.

    Thirdly, health workers maintained that HIV disease management is a speciality skill. They argued that requiring all health workers to learn how to manage HIV treatment overnight was not feasible because of continuous updates in HIV treatment protocols. Also, the one-on-one touch by clinicians in HIV care would be hard to maintain in general clinics.

    Fourthly, there’s the problem of numbers. HIV clinics in Uganda were described as “a hospital within a hospital” because of the large patient volumes. Uganda has 1.6 million people living with HIV with 898,200 enrolled on antiretroviral therapy in 2016. This suggests that the sheer volume of HIV clients at health facilities is too large simply to be merged with the general pool of patients.

    What we found

    Most studies evaluate integrating HIV with non-HIV services under experimental settings. Our study is different in that the majority of health facilities we surveyed had actually experienced having specialist HIV clinics, as well as been through the experience of integrated care.

    Several hospitals we visited had reverted back to a stand-alone clinic model after failed attempts at integrating HIV with non-HIV services. Health workers and patients cited a number of reasons for this happening. These included:

    • The chaos that ensued when all hospital laboratory services were brought under one roof. This included multiple accounts of HIV patient samples being lost.

    • The increased workload while implementing an integrated package of services.

    • A shortage of physical space.

    • The ability of health facilities to conduct HIV and non-HIV laboratory tests concurrently.

    • The absence of counselling rooms when facilities were integrated into general out-patient services. This affected the ability to offer HIV positive patients’ privacy.

    • Increased waiting times in integrated facilities.

    What next

    Our study suggests that a wholesale switch to integrated health services is not feasible and a more incremental approach is advisable. From our findings it is clear that the health system in Uganda is unprepared for integrated care.

    Retraining health workers, preparing people for the changes and shortages of space are among the issues that need to be addressed. Blanket integration policies are impractical and need to be tailored to country context.

    The Conversation

    Henry Zakumumpa received funding from The Wellcome Trust (UK) through the Consortium of Advanced Research Training in Africa (CARTA).


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    Suicide is increasingly recognised as a global health challenge.Love the Wind/Shutterstock

    Suicide is increasingly recognised as a global health challenge by the World Health Organisation who call for society-wide efforts to prevent suicide.

    In a recent study, we set out to understand the drivers of suicide for young men in Meru county, in central Kenya. We wanted to know whether young men in the region were more at risk of contemplating suicide if they have more friends and family who have attempted, or committed, suicide.

    Previous research has found that incidents of suicide and emotional states contribute to suicidal thoughts passing among networks of friends and within families. Part of the familial link may be genetic, but evidence shows that social pathways – like the transmission of considering suicide as a viable option and devaluing one’s own life as a result of a peer’s self destructiveness – also exist.

    If we identify factors that predict why young men consider suicide as an option, we can potentially stop suicides before they happen.

    Contemplating suicide

    Using surveys, we randomly interviewed 514 young men (aged 18-34 years) in the Igembe sub-counties of Meru County. We used the Modified Scale of Suicide Ideation– a scale that assesses the presence or absence of suicidal thoughts and how severe suicidal ideas are – and coded for only the most severe cases.

    We found that, over two days, around 12% of men engaged in severe suicide ideation – they prepared a plan to end their lives, and considered their own death with concerning intensity or frequency. Though global lifetime estimates of considering suicide range between 14%-33%, our survey specifically screened for more severe suicide ideation, as opposed to more common passing thoughts about ending one’s life.

    Among young men who reported that none of their friends had completed suicide, the percentage who had contemplated suicide was 5%. This is much lower than the percentage of respondents who engaged in severe suicidal ideation if they had one friend who completed suicide (17%), and higher still if respondents knew two or more friends who completed suicide (32%).

    Similarly, the prevalence of suicidal thoughts increases with the number of friends who attempt, but don’t complete, suicide. If a family member completed suicide during the respondent’s first 18 years of life, the risk for present suicidal thoughts increases by 20% in the respondent’s young adulthood. These patterns are consistent regardless of education, age and household wealth.

    Explanations

    Consistent with other studies, we found a relationship between self-esteem, loneliness and suicide that may explain this pattern. Men who reported more suicide among friends and family, reported lower social self-esteem, a predictor of suicide behaviour. Men who reported lower self-esteem also reported more loneliness – described as the pain felt when they believed they didn’t belong socially and emotionally.

    The image is therefore that men who have experienced suicide in their social groups think their social groups are less valuable and experience loneliness. They then experience less meaning in life and thoughts of ending their own life can begin to form.

    Prior research also finds that our thoughts about ourselves are influenced by the self destructive behaviours of our peers. We can internalise their emotions and behaviours as though these emotions and behaviours were our own through a process called projective identification.

    Peer suicide doesn’t affect the majority and identifying social and psychological factors that lead to resistance needs more investigation, and likely includes making meaning from the tragedy.

    Implications

    The implications of this research are multi-fold.

    As with many countries, Kenya lacks enough mental health resources to meet the demand for services. Resources to prevent suicide in the future should target young men who are friends or children of those who have attempted or completed suicide in the past. This includes identifying and following-up with friends of suicide attempters who come to emergency health centres.

    Efforts should focus on group support and gratitude interventions which encourage people to remember at least one thing they are thankful for each day by writing or drawing it down. Gratitude interventions can improve one’s sense of meaning in life and reduce suicidal thoughts.

    Faith, community, education and other leaders should be sensitised to the challenges faced by those who remain behind after a loved one’s suicide.

    And finally, media campaigns should be promoted that improve awareness and reduce stigma related to mental health issues.

    The Conversation

    Michael Goodman receives funding from the University of Texas Medical Branch in Galveston, TX. He is affiliated with Sodzo International.


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    Roasted mopane caterpillars are eaten in Livingstone, ZambiaRainer Lesniewski/Flickr

    Insects could be a game changer in the race to combat food insecurity and achieve zero hunger – the theme of this year’s World Food Day.

    Eating insects can help fight hunger and food insecurity. They are a fantastic source of nutrients – like protein – and food at times when the production of commonly eaten staple African food crops, like maize, fails due to the changing climate, droughts, or insect pest damage.

    Eating insects is an ancient practice which is still prevalent today. About two billion people, more than a quarter of the world’s population, eat insects. Most live in Africa, Asia and Latin America.

    Insects should be tapped into as an excellent tool to fight hunger and malnutrition because they are abundant, healthy, have less of a carbon footprint to produce and can offer a range of business opportunities.

    Why eat insects

    Abundant: Insects are abundant in Africa. The continent is home to over 1900 edible insect species – mostly beetles, caterpillars, grasshoppers, wasps and ants.

    And insects reproduce quickly and have high growth rates. Insects can attain maturity in less than a month. Most insects take three weeks or less to complete their life cycle. At the same time, farming insects doesn’t require much land and water as traditional agriculture does.

    Insect farming is already happening in Africa. In Kenya, for example, crickets are produced in buckets and crates where female adults lay fertilised eggs under a wet cotton wool. After a month, the eggs hatch into nymphs that feed on vegetables, soy flour and water. It takes three months for crickets to mature into adult stage. In Zimbabwe, Mopane Worm Enterprises grow trees on to which the moth lays its eggs. These then hatch and the larvae feed on the leaves. It’s at this stage that the Mopane worm is harvested.

    Healthy : Insects can serve as sustainable alternative sources of proteins and other nutrients. Insects are rich in essential amino acids and protein. They are sometimes superior per ounce, to traditional protein sources including beef, chicken, goats and sheep. Nutritional benefits can vary from one insect species to another. For example, the Orthoptera group of insects, that contains grasshoppers, yields the highest protein content.

    Better for environment: Agriculture and livestock, are major sources of greenhouse gas emissions. Unlike agriculture, insects produce far fewer greenhouse gases: one-tenth the methane and one-three-hundredth of nitrous oxide.

    Money makers: Insects, provide an opportunity for entrepreneurs to think outside the box. Millions of Africans are already eating them and new businesses could be developed. They can be eaten as they are, or processed – for instance into protein powders to serve as supplements. Several start-up businesses have been launched focusing solely on producing insects for human food and animal feed. These range from countries like Netherlands to South Africa and Kenya.

    Evidence

    Insect eating is widespread in Africa.

    In Cote d’Ivoire, a recent survey reported that over 59% of the surveyed respondents were eating insects. Similarly, in Zimbabwe, a recent survey reported most of the people surveyed had eaten insects. Consumption happens mainly in rural areas, rather than in the cities.

    In South Africa, insect eating is normal. Topping the list is the Mopane caterpillar – a delicacy that’s eaten in other African countries too, such as Zimbabwe and Namibia.

    In Kenya, farmers and entrepreneurs are increasingly turning to eating insects to fight hunger. Termites, for instance, are being eaten by small-holder farming families to supplement meals due to failed harvests. Farmers are also rearing insects to sell in local markets. A recent survey in Kenya, showed that over 80% of respondents said they ate insects, with termites, and lake flies topping the list. Others eaten include grasshoppers, locusts, ants and crickets.

    Rolling it out

    Tapping into insects to fight hunger, food insecurity and malnutrition doesn’t come without some challenges.

    As an entomologist – that has maintained insect colonies in the laboratory – I know firsthand about what these are. Managing insects needs careful attention and management. This includes regulating temperature, humidity and observing high hygiene standards, since insects are highly susceptible to microbial and bacterial infections. At the moment there aren’t any laws governing this. New legislation must also be put in place to ensure that entrepreneurs that decide to venture into insect farming maintain proper food and hygiene standards.

    As challenges, like droughts linked to climate challenge, continue to exacerbate food security challenges, insects provide an opportunity for innovation.

    The Conversation

    Esther Ndumi Ngumbi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.


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    Tik users' teeth are often damaged by their habit. Shutterstock

    Crystal methamphetamine is the most widely used synthetic drug in the world, according to the United Nations Office on Drugs and Crime. It’s an extremely addictive stimulant that dramatically affects the central nervous system.

    The drug is widely used in South Africa, with particular hotspots in the Western Cape province where it is referred to as “tik” due to the “ticking” sound it produces when smoked. Cape Town appears to be the tik capital of South Africa; about 98% of methamphetamine patients seen across the country come from this city. Tik is used as a recreational stimulant and can be swallowed, snorted, injected or smoked. In its smoked form it is often referred to as ice, crystal, crank and glass. Smoking is the most dangerous way of consuming the drug, as it provides quicker access to the brain and bloodstream.

    People who use the drug experience feelings of wakefulness, energy, a sense of well-being, and euphoria. But crystal methamphetamine abuse has devastating effects: it can cause lung disorders, kidney damage, hyperthermia, stroke and cardiac arrest. But, one of the least researched areas is the extensive tooth decay and gum disease that it causes.

    A team at the Tygerberg Oral Health Centre at the University of the Western Cape’s faculty of dentistry traced how tik affects users’ teeth and gums. Tik causes serious mouth and teeth problems commonly known as “meth mouth” – that presents as extensive tooth decay and gum disease. Once the damage begins, it is virtually impossible to stop and in many cases leads to multiple tooth extractions. Based on our findings we recommend early diagnosis to prevent the rapid and extensive deterioration.

    Education is also key – not only within communities and for the users, but also the education of other health care workers (nurses, social workers and medical practitioners) so they can recognise the oral and dental signs of methamphetamine use.

    The effects

    My colleagues and I at the Tygerberg Oral Health Centre noticed an increase in the number of young adult patients presenting with multiple badly decayed teeth. We saw an unusual pattern of tooth decay. These patients presented with cavities on the smooth surfaces of the teeth, leading eventually to total destruction of the tooth.

    One of the side effects of tik is hyposalivation (causing a dry mouth). This lack of saliva has serious consequences. The ducts of the salivary glands produce saliva that is the primary defence in fighting bad bacteria in the mouth, buffering acids and protecting the teeth. The enzymes in saliva keep the mouth moist and in a state of homeostasis; that is, a pH balance with just the right amount of acid in the mouth.

    Meth mouth is one of the devastating effects of abusing tik.Author supplied

    In mechanisms still being studied and debated, the use of tik affects the actions of the salivary glands and inhibits the secretion of saliva, causing a dry mouth. One theory is that the drug causes a narrowing of the blood vessels in salivary glands, decreasing the flow of saliva. Others argue that the use of the drug affects those parts of the brain that control the salivary glands.

    But the consequences of a dry mouth go even further. To counteract the very dry mouth, tik users consume vast amounts of sugary, fizzy drinks. With no or very little protective saliva in the mouth, this creates the perfect acidic conditions for rapid wear and tooth decay by weakening the teeth’s surface enamel.

    To exacerbate matters, tik users often grind their teeth because of drug-induced hyperactivity, anxiety and nervousness. This causes accelerated tooth wear. Furthermore, they lose interest in basic personal and dental hygiene. A tik “high” can last for days; users don’t bother brushing their teeth for extended periods causing plaque to accumulate and the bacteria to continue metabolising sugars into acids. The acidic environment often leads to erosion and when mouth pH drops below critical levels, tooth decay is the result.

    What we found

    The research team recruited a sample of over 300 Cape Town patients between the ages of 21 and 29 years, making their study one of the largest of its kind. The study confirmed the harmful effects of tik use on oral health, as well as highlighted the impediments to treatment. Methamphetamine users are not easy patients to treat as they are often paranoid and unpredictable.

    Users usually seek dental care for pain. But by that stage, most of the teeth are already badly decayed and need extraction or several sessions to repair. But, once the pain is gone, most patients don’t attend repeat appointments.

    Dental disease is a distinct comorbidity in tik users and requires the development of comprehensive treatment plans that address both its abuse and the oral and dental health problems.

    Dentists should be trained to identify users presenting in their clinics, as should other health care workers (nurses, doctors, community health workers) and addiction specialists who need to be aware of oral health problems among tik users. Combating the public health problem and social nightmare of tik abuse requires buy-in from government, industry and society. And perhaps seeing images of a “meth mouth” might go some way in putting anyone off drug use for life.

    The Conversation

    Sudeshni Naidoo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.


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    Rift Valley fever is a disease passed from mosquitoes to animals then to people.Shutterstock

    The concept of One Health is deceptively simple: it’s the recognition that human, animal and environmental health are all inherently linked.

    Put into practice, it means approaching global health issues such as disease outbreaks and antibiotic resistance with the combined force of doctors, veterinarians, environmental scientists and civil society to tackle them more effectively across multiple fronts.

    Taking on health issues from different angles simultaneously has the benefit of saving time, money and lives, rather than addressing a challenge in one area only to later find it emerge in another.

    While this concept has proven particularly popular among veterinarians, the wider implementation of One Health practices has remained relatively low. For instance, our team reviewed more than 1 800 scientific articles on One Health published since I coined the term in 2003. Only seven papers describe an effort to measure the benefits of the approach.

    Research coordinated by EcoHealth Alliance, a global environmental health organisation, set out to show how we can better anticipate disease outbreaks by joining forces. This can allow us to keep ahead of new public health threats and take preventative measures to protect people and animals.

    Focus on Rift Valley Fever

    We focused on Rift Valley Fever, a viral and zoonotic disease, as a test case to demonstrate the value of adopting a One Health approach, and found both scientific and resource efficiency advantages.

    Passed from mosquitoes to animals and from animals to humans with no known treatment, Rift Valley Fever is one of the World Health Organisation’s eight priority diseases and has all the elements that could quickly turn it into a global public health emergency.

    In humans, mild cases can cause flu like symptoms that last from four to seven days. Rift Valley Fever can also cause severe illness such as hemorrhagic fever with symptoms ranging from vomiting blood, passing blood in the faeces, or bleeding from the nose or gums. Almost half of the people who get this form of the disease die.

    Rift Valley Fever causes severe illness in animals. Around 90% of lambs that get infected die. The abortion rate among pregnant ewes that get infected is almost 100%.

    Recent outbreaks in Kenya, Rwanda and South Africa have put health authorities on high alert. Some authorities restricted the movement of livestock and even temporarily banned the sale of meat. And there is increasing concern that Rift Valley Fever could spread to Europe.

    Rift Valley Fever is an ideal candidate for a One Health approach because of its complex overlapping human, animal and environmental elements.

    Given there is as yet no cure for the virus, the better equipped we are to preempt outbreaks, the quicker we can mobilise to prevent them from spreading and putting animals and people at risk.

    Our research found that by tracking a disease with a combined, One Health approach, we could get a bigger, more accurate picture of the way it was spreading. This would allow us a greater opportunity to take preventative measures to protect people and animals, and save lives.

    Modelling disease interactions

    To show how this could work, we built a computer model of the complex disease interactions in people, cattle and mosquitoes based on real-world data from our field project to demonstrate possible outcomes.

    We then ran simulations to compare two approaches: a One Health surveillance system with joint human-animal sampling at the same time and place, and the more traditional approach of independent human and animal surveillance conducted separately.

    Our simulations demonstrated that the One Health sampling approach could detect associations in disease transmission between animals and people that would have been missed in typical, non-integrated study designs.

    Our research in the field also found that a One Health approach saved up to 35% in spending on staffing and resources when compared to conducting separate surveillance or studies.

    We also found that engaging the private sector, such as ranchers, farmers and their associations, which are often left out of One Health efforts, dramatically improved the efficiency and impact of the work.

    Engaging small-scale farmers was particularly important. But, in Kenya, where Rift Valley Fever was first detected, and throughout sub-Saharan Africa, convincing smallholder farmers to keep their flocks and herds vaccinated can be challenging if they do not see an imminent risk.

    In many parts, outbreaks happen once every five to six years. So many farmers do not see the return on the cost of vaccinating animals annually as well as with every new lambing and calving season, which can be up to three times a year.

    Ultimately, the only way for us to reduce the risk of Rift Valley Fever ever becoming a pandemic is to vaccinate livestock.

    We can be better prepared to tackle diseases before they take hold and avoid the devastating consequences, but only if environmental scientists, veterinarians and doctors work together and with the public. This is no easy or inexpensive task but our findings indicate that the returns on investment are manifold, for all of us who share one health.

    The Conversation

    William B Karesh receives funding from U.S. Agency for International Development. The US Dept. of Defense Biological Threat Reduction Agency funds the research on Rift Valley Fever.


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    The WHO recommends HIV viral load testing to monitor people on ARVs. Shutterstock

    A United Nations initiative backed by global experts has set its sights on an ambitious programme to bring an end to the AIDS epidemic by 2030.

    The 90-90-90 strategy aims to do this by reaching three targets: 90% of all people with HIV must know their status, 90% of those diagnosed with HIV must receive antiretroviral therapy, and 90% of people receiving antiretroviral therapy must be virally suppressed. When a person is virally suppressed it means the virus in their blood is undetectable. The last goal is informed by evidence that people with a suppressed viral load are less likely to transmit HIV to others.

    But a couple of steps still need to be taken before these goals can be met. The first is large scale community based HIV testing that aims to get people tested on an annual basis at the very least. The second is linking testing to care. This is critical because it addresses the gap between a person being diagnosed with HIV to when they start antiretroviral therapy.

    The third step is the close monitoring of people taking antiretroviral medication. The World Health Organisation (WHO) recommends viral load testing as the primary method of monitoring people on antiretroviral therapy. Viral load is the measure of the amount of HIV in a person’s blood and is used as a measure of how well a person is responding to HIV treatment. The lower the viral load the better the health outcomes.

    WHO guidelines advise that all patients on antiretroviral therapy receive a viral load test at six months and 12 months, and annually thereafter if the patient is stable. But very few patients receive that level of care.

    The main barrier is the time it takes to get test results back from laboratories that are often situated great distances from clinics. One way round the problem is to enable viral load testing to take place at primary health care level – what’s known as point-of-care viral load testing. This would be a game changer. Results would be known immediately and health workers could intervene swiftly by evaluating antiretroviral treatments in real time. This would, in turn, improve treatment outcomes.

    But achieving this requires innovation. A new approach is being piloted. The idea is to test if point-of-care viral load monitoring is in reach.

    Testing

    Monitoring the viral loads of people on antiretroviral therapy is an essential part of HIV management. Viral load testing helps doctors determine if a person is taking their medication as prescribed. It also helps to determine if patients are on the correct combination of antiretroviral drugs.

    It’s a key part of the arsenal against HIV because research shows that people who are virally suppressed are less likely to pass on the virus to someone else. That makes it a key factor in breaking the cycle of transmission.

    The most efficient way of doing this is through point-of-care testing sites. These are based within the community so that patients don’t have to travel long distances to get tests done as well as to receive treatment. This new model is being piloted with the aim of providing convenient access to care for patients.

    Currently nearly all viral load testing is conducted in centralised and designated laboratories. This means that there can be lags in getting results back to the field. Patients can wait for weeks.

    Laboratory based viral load testing is also expensive. Point-of-care testing is also cheaper than lab-based viral loads: health care workers could do the test rather than highly paid technicians.

    Small steps have been made in the direction of enabling viral load monitoring to be done at point of care.

    But additional equipment is also needed. Pilots evaluating point-of-care viral load testing are ongoing. A pilot is being run using a portable testing machine – the m-PIMA HIV1/2 – that fits on a desk top and can provide an accurate reading of viral load in under 70 minutes.

    The machine is being tested to establish whether it meets WHO standards. Once it is given the stamp of approval by the WHO, ministries of health can start the implementation at all sites.

    Closing the gap

    All countries still struggling to bring the HIV pandemic under control are focused on achieving the 90-90-90 goals.

    South Africa, which still has the biggest HIV epidemic in the world, with 7.9 million people living with HIV, is no exception, and is making significant progress.

    It is edging closer to the target of having 90% of people with HIV knowing their status. And it’s made significant progress on the second target that 90% of people with HIV should be on treatment.

    But it has some way to go on the third. While the country is on track to meet the goal that 90% of people on treatment be virally suppressed, it’s advances on this front haven’t been uniform. Some regions of the country still lag behind others. Being able to roll out point of care testing would go a long way in helping close these gaps.

    The Conversation

    Glenda Gray is the deputy chairperson of the Orange Babies Charity in South Africa, director of HCRISA, president and CEO of the South African Medical Research Council and a board member at the NRF. She is writing this article in her personal capacity.


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