Photo: Kristy Siegfried/PlusNews

Siphiwe stopped taking her medication four months ago

SITEKI, 25 March 2009 (PlusNews) – Siphiwe*, 14, has not been to school for two years but can still fit into her uniform. She has a strain of tuberculosis (TB) that is resistant to most first-line drugs and can take two years or more to treat, but she stopped taking her medication four months ago.

She is reluctant to give a reason, saying only that the tablets were “becoming bitter”, but there are a number of possible explanations. She had already endured six months of walking to her local clinic in Siteki in Swaziland’s eastern Lubombo Region to receive painful daily injections, and was swallowing 11 pills a day, including antiretroviral (ARV) drugs to control her HIV infection.

TB patients who are resistant to two or more first-line drugs are managed by Swaziland’s National TB Programme in Manzini, about 60 kilometres away, which meant that Siphiwe and her aunt, who is also her caregiver, had to beg and borrow money from neighbours to have bus fare for her monthly appointments.

There was also the daily struggle to find food to take with her pills, and the three-kilometre walk to collect water. Her aunt is blind, so these tasks fell to Siphiwe, despite her obvious difficulty in breathing and persistent cough.

“I tried talking to her about taking her pills,” said her aunt, “but sometimes she was taking them without food and it made her sick.”

Response lagging

Swaziland’s capacity to deal with patients like Siphiwe is far behind the need, despite recent efforts to devote more resources to the problem. The World Health Organization (WHO) has estimated that about 200 cases of multidrug-resistant (MDR) TB occur annually in the population of about one million.

Diagnosing drug-resistant TB is difficult and time-consuming; only the national laboratory in the capital, Mbabane, can do the necessary culture tests, which take about eight weeks. So far, only about 100 MDR-TB cases have been detected, according Dr Kefas Samson, a TB specialist with WHO.

Most hospitals do not have the space to isolate drug-resistant TB patients, so they do not admit them. Health workers had been hoping that a new national 200-bed TB hospital in Manzini would cater to them, but so far the hospital has only admitted around 20 patients.

Themba Dlamini, manager of the National TB Programme, said construction of the hospital began before the advent of drug-resistant TB, and until proper infection control was in place they could only admit patients with confirmed cases of MDR and extensively drug-resistant (XDR) TB who were infectious or too sick to be managed at home.

Patients have to come to the clinic to receive the daily injections, but many of them are too weak to walk; some have to be pushed in a wheelbarrow

For now, patients who have other strains of drug-resistant TB or are awaiting the results of culture tests, will continue to be managed as out-patients.

Susan Elden, a public health specialist funded by the Nuffield Centre for International Health and Development in the UK, who is helping to implement HIV and TB programmes at Good Shepherd Hospital, questions the degree to which they actually are being managed.

“Patients have to come to the clinic to receive the daily injections, but many of them are too weak to walk; some have to be pushed in a wheelbarrow,” she told IRIN/PlusNews.

While many patients contract drug-resistant TB after failing to complete treatment for primary TB, it is also possible to contract a drug-resistant strain of the airborne disease from another patient.

Measures to prevent MDR-TB patients infecting other members of their household are lacking in Swaziland. Some patients in Lubombo were given tents as a temporary solution, but Elden said they complained of the cold weather and gossiping neighbours, so few used them.

Only a curtain divides Siphiwe’s one-room home; she sleeps on a mat next to her 12-year-old cousin on one side, her aunt on the other.

The centralisation of MDR-TB management has also made it difficult to track patients, so that when one defaults on treatment, the information often does not filter down to their local health facility. “I think there’s been a big communication breakdown with these patients,” said Elden.

Programme still developing

The Ministry of Health is about to release guidelines for standardizing the treatment of MDR-TB patients, but Thabo Kunene, regional TB coordinator in Lubombo, pointed out that local health facilities do not have the infrastructure or the expertise to manage such patients. “There are only three doctors with MDR-TB expertise, and they’re all in Manzini,” he said.

WHO TB specialist Samson pointed out that Swaziland was still in the process of strengthening and decentralizing its response to primary TB, and it would take time to develop a more community-based approach to drug-resistant TB.

“A community-based component is one of the strong elements in the [new] guidelines, but the programme is still developing,” said Samson. “Before you roll out to clinics and communities, it goes with sensitization of staff at that level.”

In Swaziland’s southern Shiselweni Region, the international medical humanitarian organization, Médecins Sans Frontières (MSF), in partnership with the health department, is preparing to implement a programme to manage MDR-TB patients in their communities.

The plan includes building small regional facilities to isolate patients until they are no longer infectious; those with adequate infection control at their homes and reliable treatment supporters will then complete their treatment in their communities. “TB villages” will be built a short distance from health facilities for patients with no one to monitor them at home.

“We want to demonstrate that this is the right approach, that this is feasible, even if it’s very labour intensive,” said Aymeric Peguillan, the MSF head of mission in Swaziland.

In other parts of the country, a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria – expected to start being dispersed in April – should provide some relief for MDR-TB patients. The grant will provide them with food parcels and transport money, and stipends for their treatment supporters.

Elden argues that it may not be enough to ensure the surivival of patients like Siphiwe. After nearly three months, results of a culture test confirmed that she is multi-drug resistant, but staff at the hospital in Manzini still insist no bed is available for her.

“We in healthcare have created the MDR situation in patients like Siphiwe through poor organisation of care, poor and inadequate monitoring, and poor drug supply,” said Elden, adding that until Siphiwe is admitted to the hospital “she will suffer from inadequate care and spread MDR to those around her.”

*Not her real name

ks/he/kn source.www.irinnews.org

Photo: Tomas de Mul/IRIN

Recent rainfall has lead to a surge in new cholera cases

JOHANNESBURG, – With resources stretched thin, aid agencies struggling to contain a cholera outbreak across all but one of Mozambique’s 10 provinces hope the approaching end of the rainy season will bring some relief.

“This year is worse than previous years, even worse than years in which we had floods. There are more cases and the fatality rate is slightly higher,” secretary-general of the Mozambican Red Cross, Fernanda Teixeira, told IRIN. Over 12,000 cases and 157 deaths have been recorded since 1 January 2009.

The latest Southern Africa Regional Cholera Update, compiled by the UN Office for the Coordination of Humanitarian Affairs (OCHA), said the highest number of cases had been recorded in the northeastern provinces of Nampula (3,033) and Cabo Delgado (2,427).

“More and more districts are affected and there is an urgent need to strengthen surveillance, preparedness and response to the cholera outbreak in Mozambique, particularly in districts with high transmission risk and border districts to countries affected by cholera,” the OCHA update said.

Not a new problem

Cholera is also ravaging neighbouring Zimbabwe� 92,811 cases and 4,077 deaths have been reported since August 2008, according to OCHA� but Teixeira said the Mozambican outbreak was not necessarily related: “Cholera has always been in Mozambique, it’s endemic.”

The cholera country profile of Mozambique by the World Health Organization notes that the disease has been present in the country since 1973. In 1992, 93, 98, 99 and 2004, notified cholera cases in Mozambique represented between one-third and one-fifth of all cases reported in Africa.

Cholera is a waterborne intestinal infection that causes severe diarrhoea and vomiting, leading to rapid dehydration. Left untreated it can bring death within 24 hours, but the World Health Organisation (WHO) describes it as “an easily treatable disease” cured with rehydration salts.

Hard to eradicate

The surge in new cases was attributed to recent heavy rainfall in a number of provinces, but the underlying factors of cholera in Mozambique have always been related to pervasive water and sanitation problems, and a chronic lack of access to health facilities.

“There are many causes, like poor sanitation in cities and in the countryside,” Texeira said. Less than 50 percent of Mozambique’s 21 million people have access to safe drinking water.

The ministry of health has been leading the response to the outbreak, with the help of partners like WHO, the Red Cross and the UN Children’s Fund (UNICEF). According to the OCHA update, health and water and sanitation were key areas in the ongoing intervention.

“Social mobilization campaigns via radio, and distribution of information, education and communication materials were being intensified in order to reduce misconceptions and mobilize community around key cholera prevention messages,” the update noted.

The need for adequate information was recently evidenced in a tragic case of ignorance when two Mozambican Red Cross volunteers were killed by the local community, who were convinced that the volunteers were deliberately spreading cholera. The incident in early March resulted in the charity organization halting its health work in the province of Nampula.

We are doing what we can with the resources we have … the rainy season will come to an end in April; usually the situation then becomes better

Providing assistance in remote areas is often very difficult. “People in rural areas don’t seek assistance, or lack access to health facilities; when they finally get there it’s often too late,” Teixiera said.

Money and weather may bring relief

The OCHA update said a US$ 875,000 donation by the United Kingdom’s Department for International Development (DFID) had recently been released to help the humanitarian community in Mozambique cover the immediate needs of the response.

In the meantime, Teixiera said, “We are doing what we can with the resources we have� the rainy season will come to an end in April; usually the situation then becomes better.”

tdm/he source www.irinnews.org

Photo: Jason Gutierrez/IRIN

Troops scour a section of Jolo’s jungle area looking for Abu Sayyaf militants in this file picture taken last year. The Abu Sayyaf had agreed to free one of three ICRC staff it kidnapped in January

MANILA,� – A hostage crisis involving three International Committee of the Red Cross (ICRC) workers may force agencies to stop bringing assistance to some areas, officials told IRIN, as humanitarian workers feel increasingly under threat in the hostile south.

Stephen Anderson, the World Food Programme (WFP) country representative, said additional protection measures for his 60 local and foreign staff were paramount as the situation in Mindanao had become “dramatically more insecure”.

“We can still manage the risk, though we have taken a number of measures in terms of security,” Anderson told IRIN. “It [the kidnapping] affects us because we are concerned about the welfare of colleagues who do the same type of work.”

Growing concern

The kidnapping of Filipina Mary Jean Lacaba, Italian Eugenio Vagni and Swiss national Andreas Notter had affected staff morale, Anderson said.

“We’ve had some staff coming in from the outside and when they are given a choice between going to Mindanao and some other place, they choose elsewhere. They are nervous. We’ve had staff who have chosen not to come here,” Anderson said.

Lacaba, Vagni and Notter were taken by Abu Sayyaf militants at gunpoint on 15 January in Jolo, a southern island and Muslim stronghold, where government troops have been battling the rebels for years.

Abu Sayyaf has not publicly demanded a ransom, although previous abductions have led to millions of dollars changing hands. Deadly clashes last week led to several Marine deaths, and dozens wounded on both sides, including the Abu Sayyaf leader Albader Parad.

Another Abu Sayyaf unit is holding Sri Lankan peace advocate Omar Jaleel from the Nonviolent Peaceforce group, who was kidnapped on 13 February on the nearby island of Basilan.

His fate remains unknown, although military reports have said he was sighted a week after he was abducted.

The kidnappers of the ICRC staff have been cornered in a remote jungle area on Jolo, and have threatened to harm the hostages if troops continued to advance. Amid the tense stand-off, Abu Sayyaf offered to free one of the hostages but then reneged.

The ICRC in Geneva said the hostages last contacted Senator Richard Gordon – chairman of the local Red Cross – on 19 March, and they were unharmed. It said the three remained together but were tired and in bad health from moving around in the jungle.

Photo: ReliefWeb

A map of the Philippines highlighting Mindanao and Jolo islands

Possible donor impact

Gordon said the abductions could scare off international aid agencies.

“The situation is very serious for our country. These are people who belong to a humanitarian organisation respected in the whole world. It is neutral and impartial in times of conflict and yet they were victimised,” Gordon said, noting that the three had been working on a project to improve the lives of inmates in Jolo’s provincial jail.

However, Lan Mercado, Oxfam country chief, said the south was “a complex environment” where aid workers had to be aware of the perils they faced.

“We need to be nuanced in our analysis and understanding of the dynamics that operate in every place in Mindanao,” Mercado said.

While security remains a major consideration for Oxfam in deciding what programmes to implement, it remains committed to helping those in need, especially those displaced by fighting, Mercado said.

“Insecurity is not necessarily a deterrent and we do work in many insecure places in the world,” she stressed.

Anderson said WFP liaised closely with troops and police before going on missions, noting that if harm befell any of its volunteers, “it ends up jeopardising the entire operation. The main thing is that we try to adhere to certain procedures that may minimise the risk to our staff. It doesn’t mean, however, that it’s 100 percent, and you can be in the wrong place at the wrong time, which sometimes is hard to avoid.”

In December, a truck contracted by WFP to deliver aid to a strife-torn area in Lanao del Sur province in Mindanao was ambushed by armed men, killing one Filipino. The attack was blamed on a Muslim bandit group.

jg/ds/mw source.www.irinnews.org

Photo: OCHA VMU

The three Darfur states showing areas where some relief agencies were shut down

JUBA/NAIROBI,� – The loss of expertise following the expulsion or closure of 16 aid agencies cannot be replaced in the short run and has exacerbated the plight of displaced people in Darfur, the UN warned.

Aid activity in Darfur, western Sudan, was a network whose operations will be affected by the expulsion of 13 international agencies and the closure of three NGOs, the UN Emergency Relief Coordinator John Holmes said in New York.

The closures were announced shortly after the International Criminal Court (ICC) issued an arrest warrant for President Omar el-Bashir on 4 March on charges of war crimes and crimes against humanity. Bashir denies the charges.

“About 1.1 million people are receiving food for March and April thanks to an ad hoc and one-off distribution by local food committees,” Ameerah Haq, the UN Humanitarian Coordinator for Sudan, said in Khartoum, announcing the findings of a joint assessment.

At the same time, the leader of the rebel Sudan Liberation Movement, Abdel Wahid Al-Nur, said he had received “alarming reports of the situation” in Darfur. Local people, he told The Sudan Tribune, did not trust aid workers sent by the government.

Ahmed Hussein Adam, spokesman for the Justice and Equality Movement, said the “situation is very bad in the camps”; four children had died in the past two days of malnutrition-related complications in Shangil Tobaya camp, North Darfur.

The assessment was conducted from 11 to 19 March in all three Darfur states by UN and Sudanese government officials.

“By the beginning of May, as the hunger gap approaches, and unless the World Food Programme has found partners able to take on the mammoth distribution task, these people will not receive their rations,” it stated.

Sudan has said the gap left by the expulsions could be filled by national relief organisations, but the UN and other international aid agencies doubt that long-term capacity exists.

Photo: Christine Madison/IRIN

A camp in eastern Chad that has hosted thousands of Darfur refugees since 2003.

Mahdi Qutbi, a senior member of the ruling National Congress Party, had said more than 200 Sudanese organisations would fill the void, including the Sudanese Red Crescent Society, which would provide food, healthcare and water.

Gaps 

According to the findings, massive gaps remain for the 4.7 million conflict-affected Darfuris, in food, health, non-food items and shelter, water, sanitation and hygiene.

Clean water will become a key issue within a month, Haq said. More than 850,000 people are being supplied with potable water by the Sudanese government, the UN Children’s Fund (UNICEF) and national NGOs.

However, within four weeks, existing funds for spare parts and fuel for water pumps will be depleted, while sanitary facilities will need urgent maintenance to prevent disease outbreaks.

Healthcare will also face severe shortages soon, with salaries of the government staff secure only until the end of April. Some 650,000 people do not have access to full healthcare.

In terms of shelter, 692,400 people waiting for materials before the rains begin will not receive them unless the UN Joint Logistics Centre finds partners to carry out the distributions and gains access to existing distribution lists, she added.

Haq said the government had cooperated with the UN during the assessment “in an open and constructive atmosphere”, adding that “all sides recognised the challenges and were committed to finding solutions”.

By the beginning of May, as the hunger gap approaches, and unless the World Food Programme has found partners able to take on the mammoth distribution task, these people will not receive their rations

She called for the lifting of restrictions on aid agencies: “Prevailing bureaucratic impediments should be lifted and security conditions should not complicate issues such as access if the people of Darfur are not to end up facing the most serious upheaval in years.”

Security fears

“The report is grim reading, but it is not unexpected: we knew the problems facing Darfur were horrendous,” said an aid worker in Darfur, on condition of anonymity.

Security fears have since continued to increase. The joint UN–African Union peacekeeping force to Darfur reported on 24 March that several attacks against aid workers had taken place in recent days.

These included an ambush by armed men on camels on 21 March on four Sudanese staff working in West Darfur for the Fellowship for African Relief (FAR) and Tearfund. One was beaten, another robbed. On 23 March, another Sudanese FAR staff member was shot dead in Kango Haraza, West Darfur.

pm/eo/mw source.www.irinnews.org

Photo: Phuong Tran/IRIN

Students have more idle time since strike (file photo)

NIAMEY,� – An ongoing three-month strike by 37,000 contract teachers in Niger threatens recent gains toward meeting the country’s Millennium Development Goal (MDG) of providing universal primary education, according to union leaders.

A skeletal staff of 7,000 public teachers is keeping schools open part-time while their colleagues on short-term contracts- who earn on average half as much� continue to strike over benefits. While teachers who are considered state employees earn up to US$240 per month, contract teachers earn at most $160 per month, according to the National Contract Teachers’ Union.

Oubandoma Salissou, with the Democratic Union of Public Workers, which represents state employees, including the 7000 teachers, told IRIN if the reduced staff cannot cover enough of the curriculum by the year-end exam and students are not able to advance to the next grade, Niger will lose ground in its quest to provide universal education.

The situation with Nigerien schools is thorny. It will be difficult to save this school year, said Salissou. Students currently attend about two days of classes per week given the reduced staff.

The rate of school-age children enrolled in primary school has increased to 53.5 percent in 2006 from a mere 25 percent in 1990. Of those enrolees, 40 percent successfully graduated to secondary education, which is more than double the rate some 20 years ago, according to the government.

For the previous school year, 1.3 million students or 57 percent of the primary school-age population, attended primary school, according to the government.

Angry

“We have been left on our own, said secondary student Abdoulaye Ousseini, 18. Our classmates have signed up to continue their studies in private schools in Niamey.” The average cost for private school tuition goes up to $240 per year.

Employed persons in Niger in 2007 earned on average $280 for the year, according to the World Bank.

For five days starting on 16 March, students protesting the teacher strike erected barricades, blocked routes and burned tires until police dispersed them.

Dispute

The head of the national contract teachers’ union, Moukaila Halidou, told IRIN the government has not respected earlier agreements to increase benefits and to transition contract workers to the better-paying state contracts after four years of service.

But the Minister of Education, Mamadou Samba, said during a public conference on 22 March that the state is short of the almost 23 million needed to pay benefits because it had hired three times as many contract workers- more than 6000 teachers – as was initially expected. He did not provide any plan to raise the funds.

Union leader Halidou told IRIN negotiations over benefits are stalled.

Year-end exams are scheduled to take place from 18 to 21 June.

pt/aj
source.www.irinnews.org