5-6 June 1998 London, UK
|
International
Seminar on Access to Treatment for HIV in Developing Countries
5-6 June 1998 London, UK |
Kasech Mussa, Nurse Counsellor
Medical Missionaries of Mary
Addis Ababa, Ethiopia
Background: Ethiopia
The total population is estimated at 58 million people. Ethiopia is
one of the least developed countries in the world. The annual per capita
income is estimated at US $100. The social indicators for human development
and the quality of life all point to a grim situation in the country. Only
45 % of the population is currently served by health services (defined
as catchment population living within 10 km radius of a health station).
According to UNICEF , as of 1997, the infant mortality rate is 101/1000, under five mortality rate is 152/1000, and maternal mortality rate is 700/100,000 per live birth. All of these statistics indicate the poor health status of the country. About 84% of women receive no ante-natal care and less than 10% of children have access to health and medical care. The utilisation rates of programs such as Mother and Child Health/Family Planning (MCH/FP) and Control of Diarrhoeal Disease range from four to 38%.
Primary causes of morbidity and mortality are malnutrition and communicable diseases associated with food insecurity, poor personal hygiene and environmental sanitation, lack of safe water supply, harmful traditional practices, and a general low level of health awareness. Beside these, the killer disease HIV/AIDS become one of the major socio-economic problem of the country. According to some statistics, the productive segment of the population, the 20-40 age group, is highly affected.
The available health services of Ethiopia reaches about 45% of the population, and consists of 89 hospitals with 12,000 beds, 160 health centres, 2,292 health stations and over 10,000 community health posts. With regard to health manpower, there are 1,658 medical doctors (or roughly one doctor per 31,360 people), 3,924 nurses, 10,839 health assistants, 14,535 community health agents and 12,219 traditional birth attendants serving in the various health institutions. These ratios are among the lowest in the world.
The Counselling and Social Services Center of the Medical Missionaries of Mary (MMM) became operational in September 1992 as a response of the Ethiopian Catholic Church to the AIDS epidemic and to the call made by the Ministry of Health to meet the huge need for care, psychological and social support for those diagnosed as HIV positive and their families. The activities of the Center are designed in such a way as to be able to initiate and encourage a multi sectoral approach towards the prevention of new infections and provision of care and support for those already infected and affected.
The major activities of the centre include:
Information on the number of AIDS cases gives only a small proportion of the magnitude of the actual problem. The reason is that for every reported case of AIDS, there several times that number of unidentified individuals who do not show any signs or symptoms of the disease, but have the virus in their bodies and can potentially transmit it to others through the various mode of transmission. In addition, there are many HIV positive people who have no access to hospitals, and therefore are not officially registered and reported.
Studies undertaken on various population groups show that the prevalence of HIV infection is progressing rapidly. The positivity rate among the urban population is 21%, with the rural population at 4.5%. The number of adult infected cases are 2.4 million, and there are 400,000 adult AIDS cases, according to the Ministry of Health (MOH) 1997.
Realities of care in low resource environment
The MMM Center is the first established organisation which deals with
HIV/AIDS in Ethiopia and serves as a referral place for persons infected
with HIV/AIDS hospitals, health centres, clinics and also from the communities.
The type of care and support provided by the centre is:
1. Psychological
When I am talking about medical facilities and treatment in a low resource environment such as Ethiopia, you may think of AZT, CD4 counts, combination therapies and other HIV/AIDS related examinations and treatments, but we have not reached that stage. In our situation even antifungals, antibiotics, antidiarrhoeal supplementary drugs or dressing materials are sometimes not available and are very expensive. The community does have traditional coping mechanisms (for example useful plants and herbal medicines) for health related issues which existed before HIV/AIDS and still functions after HIV/AIDS. These and other coping mechanisms have been very helpful for prolonging the life of the client.
In terms of social support for our clients and their families, we sometimes can offer material support such as providing cloth, grain, or cooking oil. Financial support is sometimes available to cover fees for rent, school, medicines, or other money support. We also provide very essential drugs.
When we see the realities of care in the situation of Ethiopia, there are a massive number of PLHA who need care and their families require support. The implications of this both for the present and the future have not yet been fully taken into account. Nor have strategic alternatives been developed by either National Government or donor agencies, who have so far been reluctant to fund care and support. Almost exclusively and understandably, the focus of international efforts in the past have rested mainly on prevention. However as more and more people become infected with HIV and develop AIDS, the nature of the response has to change.
In Ethiopia, the HIV/AIDS epidemic has greatly increased pressure on both the formal and informal care system. Because AIDS is incurable, chronic, and sexually transmitted, it is usually poorly discussed and poorly understood.
AIDS is a very expensive disease. It reduces average families to poverty and brings the poor to the point of complete destitution. For most families AIDS is not only a devastating illness, but an economic calamity, through the loss of all one's money trying to find a cure. By the time clients come to the centre, almost all have no money left. The inability of health institutions to provide HIV sero-testing and counselling puts people into a dilemma about their health problems and they start to invest whatever money and time they have going from one hospital to the other and/or trying other cultural alternatives in search of cure. This puts strain on the economic status of a family which in turn will reduce the life span of the PLHA and other vulnerable family groups. For the low income groups of society, it is essential to address this problem.
Clients who cannot come to the centre for medical care are visited and cared for at home. It is obvious that the family members are the ones who are highly involved in care provision. Counsellors assess the needs of the families in the areas of counselling, finance, material, information, nursing and medical advice and try to fill the gaps as needed. Community home based care is a new programme recently developed by the centre. This purpose of this programme is to raise awareness of the community so members can give care and support to PLHA and their families and further more, see the problem as their own.
Generally in Ethiopia
1. AIDS is not only a medical problem, rather a development issue.
2. AIDS has no cure and thus the need to focus on care and support
as well as prevention should be promoted.
3. It requires education, working with vulnerable groups.
4. It is an ECONOMIC issue and also GENDER issue.
Problems faced/limitations
1. No voluntary counselling and testing facilities.
2. Very limited commitment by government, which has no HIV/AIDS policy.
3. Financial and material scarcity compared to the magnitude of the
problem.
4. Problem of medicine and medical supplies:
* essential drugs and anti fungals
are very expensive and often not available.
* limited hospital and other medical
facilities.
5. For this and other reasons, most AIDS cases are cared for at home
6. Shortage of skilled and committed man power, insufficient patient
care and support system, which would work for and at the grass root level.
Suggestions/Recommendations
1. Government should be committed to face the problem of HIV/AIDS.
2. Accord HIV/AIDS the national priority and recognition it deserves
as well as declare AIDS a national emergency and take the appropriate measures
to tackle the epidemic.
3. The mobilisation and pooling of resources (financial, material,
human) deemed most essential.
4. Voluntary counselling and testing facilities should be available.
5. The importance of encouraging and stimulating community based activities
in general and care in particular highly emphasized.
To conclude, care in low resource environment like Ethiopia helps PLHA
to live positively with the virus as well as to contribute their knowledge
and skills for the development of the country. If they are to receive proper
care, counselling, material, financial, and medical assistance are important
elements.
MANY HANDS MAKE LIGHT WORK
LET US UNITE TO FIGHT AGAINST AIDS
Discussion:
Ms. Mussa was asked about the importation of essential drugs and what
the international seminar might do in support of this. She said she was
unsure of what could be done. When her organisation was set up six years
ago, they tried unsuccessfully to get the government to establish a policy
on HIV/AIDS. As a result, they have to beg the government for resources.
There is a question about to whom should they address the problems of the
community? Who is responsible? The government has its priorities and at
present Ethiopia is involved in hostilities with Eritrea.
Dapheton Siame from Chikankata Hospital in Zambia pointed out that even simple drugs to treat diseases such as malaria are not available in Zambia. There are great ethical problems to justify the high cost of AIDS drugs in view of the many treatments needed for other diseases, such as TB. The priorities for different drugs pose difficult questions.
