common ground

African Health Issues

Program 0223 June 4, 2002

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

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

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

PORTER: And I'm Keith Porter.


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

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

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

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

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

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

WHITNEY: For this clinic?

USTE: For this clinic. So yeah, its….

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

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

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

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

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

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

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

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

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

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

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

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

[sound of a car starting]

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

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

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

[Many people talking with Sister Kapola]

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

[people talking in the makeshift tavern]

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

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

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

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

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

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

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

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

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

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

[sound of a TB patient coughing]

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

[sound of children talking in the TB hospital]

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

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

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

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

[sound of people and vehicles in a busy area]

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

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

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

[sound of children playing in a river]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

WHITNEY: Do you think it’s true?

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

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

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

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

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

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

[sound of someone banging on a pipe]

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

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

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

[sound of women singing and chanting]

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

[sound of women singing and chanting]

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

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

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

[sound of people making pots]

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

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

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

[sound of a rainstorm]

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

[sound of a motorcycle]

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

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

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

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

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

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


PORTER: Cassettes and transcripts of this program are available. The transcripts are free; cassettes cost $5.00. To place an order or to share your thoughts about the program, write to us at: The Stanley Foundation, 209 Iowa Avenue, Muscatine, Iowa52761. Please refer to Program Number 0223. That's Program Number 0223. To order by credit card you can call us at 563-264-1500. That's 563-264-1500.

MCHUGH: Transcripts are also available on our Web site: Commongroundradio is all one word. Our e-mail address is For Common Ground, I’m Kristin McHugh.

PORTER: And I'm Keith Porter. Cliff Brockman is our Associate Producer. B.J. Liederman created our theme music. Common Groundis produced and funded by the Stanley Foundation.

© 2002 by The Stanley Foundation

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