Beside the great Lake Kivu, beneath the shadow of an enormous volcano, the Rwanda-DRC border divides the neighboring cities of Gisenyi and Goma. As the day begins, the predominant impression is one of movement, as people walk in either direction through the customs checkpoint, carrying giant bunches of green banana, stacks of nesting plastic chairs, anything that is tradable. They form an unbroken stream of humanity crossing to and fro, the tall border signboards towering overhead.
I was glad to read the announcement made by World Bank President, Dr. Jim Kim, at the start of this year’s UN General Assembly meetings, about the Bank’s projected financing support through the end of 2015 to help developing countries reach the Millennium Development Goals (MDGs) for women and children’s health. As we move toward the culmination of the MDGs in 2015 and beyond, preventing maternal and child deaths should be seen by all government delegations and their partners in the international development community as a clear yardstick to measure their commitment for creating more just and inclusive societies.
My experience as a doctor who practiced actively in this country did not prepare me for the shock I had during the preparation of the Nigeria State Health Investment Project. I had worked for three years in the public sector at the beginning of my career but then spent more than a decade in the private sector. I had not imagined the decay in public infrastructure – leaking roofs, heaps of garbage, broken down equipment, and stock-outs of drugs and disposables for months on end in public health centers. The general morale of frontline health workers was low and some ingenious workers were actually buying their stock of drugs to provide services for patients. Not surprisingly, the utilization of health services was low and the quality of service appalling.
Growing up in India, mosquito nets were an essential part of life. I slept under them as a child in Bangalore, with their ropes tied to bedposts, doors, closets, window grills—anything that would offer support at the right height. It was like pitching a tent every night, and the occasional dramatic collapse would result in much helpless laughter. Later, going to college on the banks of the slow-flowing Koovam river in Madras (now Chennai), I tucked myself under a net in my dormitory at about 6 p.m. to avoid the twilight assault of mosquitos from the water. In fact, particularly after a bad attack of malaria when I was a child, a lot of my life was lived perforce under a mosquito net, until electric repellent gadgets reached the market and nets somewhat lost their popularity.
Recently, sitting in Halima Ibrahim’s house in Majengo, a neighborhood in the coastal city of Mombasa, and talking about the new mosquito nets her family had just received from the Kenyan government, I felt instantly at home in her tiny living room. It was packed from corner to corner with family and friends, all brimming with opinions about nets old and new. Everybody talked about malaria and what a problem the disease was in the community. The nets that had just been distributed to them free of cost would make a huge difference, they said, protecting them from being bitten by mosquitos, and saving them considerable expense. Many of the families on the street simply could not afford to buy durable and effective nets at the prices they commanded in the local market.
As our sturdy Land Cruiser inched its way down a precipitous dirt track, trying to descend from a high ridge into the Rift Valley, I wondered what might happen if we had an accident here in the heart of Kenya’s remote Samburu County. Mobile signals had faded soon after we left the town of Maralal several hours before. We could have tried to walk back, but would have been very unlikely to make it before nightfall. Luckily, after a few mishaps and some serious jolting, we arrived at our destination in the valley—lonely Suyan manyata, whose distant circular outline we had seen from the ridge.
Talking to some of the women in the manyata, I realized that the ground that we had covered to get to them was nothing. We had done it in good health in a vehicle built for difficult terrain. As they told us what life was like in their village, my heart quailed at the thought of enduring a bumpy ride in a run-down van if one were pregnant or in labor with complications—if at all transport could be obtained. Just a few days ago, a child had died here of malaria, the women said. How did they usually get help, I asked. “We send our fastest runner 18 kilometers to the nearest dispensary,” said Ma Toraeli, a grandmother in the village. “From there someone comes to help us”. Health workers also visited the village from time to time, she said, to immunize babies and perform other routine checks.
Immunization seemed high on people’s minds in Samburu. Later that day, we visited Barsaloi, a larger village with its own government dispensary and another run by Catholic nuns. The two stood side by side, with a well-worn path between them. There I met another grandmother, Agnes, who had brought an infant girl, Salini, to be immunized, although her record showed that she was early and didn’t need this service yet. But while Stephen, the clinical officer at the government dispensary, was examining the baby and we were on the subject of immunization, the district head nurse showed us how vaccines were stored at the required temperature in the two-room government dispensary without power supply.
Working in development, there are some faces you never forget because they come back to you at the end of a long day, time and again. As we recognize International Day of Action for Women, I’ve been thinking about some of these faces from a recent trip to Sudan. Faces of young women who are doing community work that is so important, it is really in a league of its own. I’d like to dedicate this “day” to these women of action, the young graduates of village midwife schools in eastern Sudan.
The doorway to the midwives school in Kassala, a town close to the Red Sea, leads you into a small courtyard crowded with beds, belongings, and cooking utensils gently baking under the desert sun. Passing through this open air dormitory, another door opens into a classroom, in which a group of about twenty young women dressed in soft white are listening to a lecture that involves plenty of gesticulating and a plastic model lying on a bed. These students have already qualified as midwives and are now in town to learn more advanced skills that they can take back to their villages in a few months.
The scientific evidence is overwhelming. As Robert Beaglehole and colleagues at the World Health Organization (WHO) pointed out years ago, tobacco is the only consumer product that eventually kills half of its regular users if they follow its manufacturers’ recommendations.
Given this dire reality, it is clear that Africa is now at a crossroads. On one hand, the countries in this region have become an attractive and under-tapped market as tougher regulations, high taxes, and greater consumer awareness of the dangers of smoking in developed countries are “closing the door” to tobacco imports and leading to significant drops in consumption. And on the other hand, cigarettes are becoming increasingly affordable as incomes rise in several African countries due to the rapid economic growth of recent years. Indeed, African countries are experiencing the highest increase in the rate of tobacco use amongst developing countries--the number of smokers in sub-Saharan Africa is projected to increase 148 percent by 2030, to 208 million smokers or one-fifth of the total population.
“Tuberculosis was a silent killer a few years ago,” says Rogers, a community health worker at the Kangemi Health Center, which assists people living with TB to receive effective treatment in a sprawling settlement on the outskirts of Nairobi.
Community health workers like Rogers are a vital link between patients and medical providers and are well respected and trusted. They educate, enlighten, and empower patients and people in the wider community. They work with the local area chiefs in mobilizing communities in the fight against TB. Rogers proudly notes that he actively identifies TB cases, provides home-based care, and traces people defaulting on treatment, all critical elements in managing TB at the community level.
Detection and management of TB are critical in Africa, where roughly a quarter million TB deaths were reported in 2010. The continent accounts for about one-quarter of the global TB burden and is facing challenges in meeting the Millennium Development Goal of reducing 1990 TB mortality rates by half by 2015. However, there is also reason for hope on TB control in Africa, as seen in communities like Kangemi. In Kenya, with support from government and partners, including the World Bank (Health Sector Support Project, Total War Against HIV/AIDS Project, East Africa Public Health Laboratory Networking Project), activities are underway to strengthen the availability of drugs, channel funds directly to lower level health centers , and improve access to the latest diagnostic tools for detecting TB. “The state-of-the-art diagnostics will go a long way to turn the tide on this pandemic,” notes Lucy Chesire, Executive Director of the TB Action Group in Nairobi. “Patients will no longer wait months to get results.”
Stevan Lee, Senior World Bank Economist, is co-author of this post.
Attracted by the prospects of large unexploited natural gas reserves in the south of Tanzania, big players are in town. The British Gas Group has publicly announced that it may invest over US$35 billion in the next 25 years – 1.5 times Tanzania’s current GDP. Policymakers and donors are jockeying to position themselves and understand what is at stake.