Journalism from the heart of crises

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  • Sending the right message on mHealth

    We’ve read the stories: From bedridden patients sending text messages to their health workers, to young people receiving HIV prevention messages via SMS, the mobile phone seems to have morphed from communications device to essential life-saver. But is the evidence there yet that mHealth is an effective health delivery intervention for the developing world?

    IRIN, like others, has been reporting for years on mHealth’s potential: This communication technology could provide the answer to distant and under-resourced health services, in particular for Africa’s poor. Kenyan health workers have recounted how mobile phones have made it easier to track their patients’ progress; there have been anecdotal reports of lower maternal mortality rates as a result of Ghanaian mothers being able to call for ambulances during labour.

    In Africa, with some 63 mobile phones per 100 inhabitants (compared to Asia and the Pacific’s 89 per 100 inhabitants), the cell in your pocket can become a direct channel for receiving public health messages, improving communication between patients and health providers, boosting data collection and, increasingly, assisting in diagnosis.

    But a systematic review - published in January in PLOS Medicine - into the effectiveness of mHealth technology in improving health delivery found mixed results from 42 trials of mHealth interventions. SMS appointment reminders, for example, were found to have modest programmatic benefits, while using phones to send digital images for diagnosis actually led to a drop in the correct analysis in two trials examined.

    A 2012 study by the mHealth Alliance, which advocates the use of mobile technologies in health care, found that sub-Saharan Africa had a higher number of mHealth projects compared to Asia and Latin America, with more than half of all mHealth projects related to communicable diseases such as HIV and malaria.

    Insufficient evidence

    Despite the rapid growth, "there is currently a gap in terms of evidence linking mHealth to improved health and operational benefits, and this is particularly true when it comes to studies in low- and middle-income countries," Patricia Mechael, executive director of the mHealth Alliance, told IRIN.

    The PLOS review found that “none of the trials were of high quality - many had methodological problems likely to affect the accuracy of their findings - and nearly all were undertaken in high-income countries.”

    Rajesh Vedanthan, an assistant professor at New York’s Mount Sinai Medical Centre who is currently working with AMPATH, an academic health programme involved in research and health care in Kenya, told IRIN via email that some of the practical challenges with the use of mHealth technology included “optimizing the user interface, ensuring that users have an easy and error-free working experience with the mHealth device, not impeding the workflow of clinicians, issues related to network connectivity, access to a central server, coordination of individual devices with a central coordinating office, systems integration, etc…

    “mHealth has the potential to assist with several aspects of the ‘supply chain’ of care for non-communicable diseases - including screening/diagnosis, linkage to care, treatment/decision support, retention and follow-up, systems coordination, etc.,” he added. “Whether mHealth will be effective in all of those arenas is still not robustly known, and rigorous research is still required.”

    A need for standards

    The mushrooming of mHealth pilot projects has caused concern around monitoring. Uganda has declared a moratorium on pilot mHealth initiatives as it seeks to bring them in line with national health policies.

    “We first needed to study them [mHealth and mHealth initiatives]… Some of these people are duplicating what is already there,” Asuman Lukwago, the permanent secretary in Uganda’s Ministry of Health, told IRIN. “As a ministry, we only implement innovations that have been tested and approved. At the moment, we are suggesting reforms to put into practice for these new innovations.”

    The mHealth Alliance recently released a review of standards in the use of mHealth among low- and middle-income countries, which found that as mobile health systems “move towards scale, existing guidelines and strategies will need to be revised to reflect new demands on executive sponsorship; national leadership of eHealth programmes; eHealth standards adoption and implementation; development of eHealth capability and capacity; eHealth financing and performance management and eHealth planning and architecture maintenance”.

    Scaling up mHealth

    Mechael noted that mHealth could only meet its potential if it was fully integrated into general health programmes, becoming “so much a part of health systems that we no longer need to use ‘m’ as a designation”, something that cannot happen unless mHealth projects move beyond the pilot phase and really reach scale at a national or regional level.

    Importantly, experts say, the use of mHealth and other humanitarian technology should be allowed to be driven by the communities who benefit from it.

    “There has been a recognition - belatedly, in some cases - of the ways beneficiaries are using technology, voting with their wallets and their feet... We can see that the most innovative models of humanitarian technology are driven by communities themselves,” Imogen Wall, the coordinator of communications with affected communities for the UN Office for the Coordination of Humanitarian Affairs, told IRIN.

    She noted that humanitarian agencies would increasingly need to increase their engagement with the private sector as partners in preparedness and response, recognizing that the private sector is no longer merely a support system, but a humanitarian service provider as well.

    OCHA recently released a report, Humanitarianism in the Network Age, which stresses the importance of information and communication in humanitarian work and urges new ways of thinking that adapt to the changing realities of communities around the world.

    “In order for humanitarian technology to meet its full potential, there must be a willingness - an openness - to innovate, to think outside the box, to test new ideas and to risk failure and success in both the processes and the deliverables - essentially, a willingness to accept change,” Wall said.


    Sending the right message on mHealth
  • In Africa, corruption dirties the water

    Collusion among government officials, unscrupulous water vendors and large farm owners results in diverted water supply lines, misappropriated funds, and failure to implement laws on protecting water sources from encroachment and pollution. These are just some of the ways corruption is denying millions of poor people in Africa access to safe and clean drinking water, experts say.

    “The impact of corruption on the water sector is manifested by lack of sustainable delivery, inequitable investment and targeting of resources, and limited participation of affected communities in developmental processes,” Bethlehem Mengistu, regional advocacy manager at the NGO Water Aid, told IRIN.

    In a 2010 report, the UN World Health Organization (WHO), estimated that around 780 million people around the world, including 343 million in Africa, did not have access to an “improved drinking water supply”, meaning a running water network, public drinking fountains, protected wells or springs, or rainwater tanks.

    Globally, an estimated 3 million deaths result from water-borne diseases annually, according to WHO.

    According to the World Bank, 20 to 40 percent of public finances worldwide meant for the water sector are lost due to corruption and dishonest practices.

    Denied water

    In Africa, climate change and burgeoning populations have caused competition over scarce water resources, at times leading to communal conflicts. Experts say corruption exacerbates Africa’s water problems.

    “More specific examples of how corruption denies poor people access to water include situations where wealthy or politically connected people use their position to unduly influence the location of a water source at the cost of the poor,” Maria Jacobson, programme officer at the UN Development Programme’s Water Governance Facility (WGF), at the Stockholm International Water Institute, told IRIN.

    According to Jacobson, the poor “don’t have the resources to participate in a corrupt system that relies on bribes”, and therefore “lose out in terms of poor water services”.

    “Poor people also have few, if any, means to enter alternative markets when corrupt public systems fail to deliver,” she added.

    A 2008 report by Transparency International (TI), a global corruption watchdog, estimated that corruption denied more than a billion people access to safe drinking water and kept 2.8 billion from accessing sanitation services.

    In Tanzania, a 2012 study published in the peer-reviewed journal Water Alternatives revealed that a large-scale agricultural and livestock farming project - on a 14 hectare plot of land in the Iringa area leased out by the government to a private company, allegedly without following the legal process - led to contamination of nearby water sources serving some 45,000 people.

    The study, conducted by the Italian NGO ACRA (Cooperazione Rurale in Africa e America Latina), said fertilizers, pesticides and animal waste from the farm washed downstream to the water points.

    “While there are mechanisms within Tanzanian law to limit potentially polluting activities, establish protected zones around water sources, and empower water-user organizations to exercise control over activities that damage the quality of water, in practice, in the Iringa region, these were not effective as many procedures were not followed,” the authors said.

    In developing countries, corruption is estimated to, according to the TI report, “raise the price for connecting a household to a water network by as much as 30 per cent,” which leads to an inflation of the “overall costs for achieving the Millennium Development Goals for water and sanitation, cornerstones for remedying the global water crisis, by more than US$48 billion.”

    In Kenya, for instance, poor people in the capital, Nairobi, pay 10 times more for water than their wealthier counterparts, according to TI.


    The incompetence of national and local authorities, too, is to blame.

    “Because the revenue that is collected from the water sector is not ring-fenced, it is not ploughed back in to improve services. It is not uncommon to see leaking and broken pipes and water pumps in many parts of urban and rural regions of Africa countries,” Barrack Luseno, a Kenyan water sector analyst, told IRIN.

    In Malawi, according to the TI report, water collection points constructed between 1988 and 2002 were mostly placed in areas where such facilities already existed, largely due to “political patronage.”

    “The key drivers [of corruption] are limitations of participation, transparency and accountability. It is usually the case that the details of sector resourcing is confined, there is limited participation of right holders in critical issues of development, and the checks and balances to key decision-making roles are weak,” Water Aid’s Mengistu added.

    Water Aid recommended in a 2012 report that governments invest more but also put measures in place to fight the runaway graft in the water sector.

    “Governments and donors must ensure that rigorous checks and balances are in place to tackle corruption and minimize waste,” said the report.

    "Poor people also have few, if any, means to enter alternative markets when corrupt public systems fail to deliver"

    It gave the example of the Ugandan government and donors moving quickly to tackle the misappropriation of funds that occurred in the country’s water sector at the end of 2012.

    “There is a continuing need to enhance the accountability of governments in delivering services and fulfilling their obligations as duty bearers. Community service organisations have an important role to play as watchdogs to ensure rights holders receive their entitlements,” it added.

    Involving communities in decision making and putting more investment into the sector are some of the ways to ensure access for more people.

    “We must ensure integrity by ensuring more openness in dealing with issues of land and water. Remember, for rural communities, access to land is commensurate with access to water. This explains the conflict between pastoralist and farming communities,” Luseno added.


    Some have advocated for the privatization of water services. In Africa, Senegal and Cote d'Ivoire are cited as privatization success stories. But critics, fearing increased prices, say that putting life-sustaining resource in the hands of for-profit companies would be dangerous.

    Karen Bakers says in her 2010 book Privatizing Water: Governance failure and the world’s urban water crisis, “an increasing consensus has developed that private sector participation in water supply will not be able, as some proponents has hoped, to succeed where governments have failed to provide water for all.”

    According to the WGF, the ideological debates over the privatization of water services “do not benefit those lacking sustainable drinking water supply and sanitation.”

    The World Bank estimates by 2007, some 160 million people were being served by private water operators globally. About 50 million of these people are served by public-private partnerships that can be considered successful.

    But privatization has produced different results for different countries.

    In Mozambique, a World Bank study revealed that access to water in the capital, Maputo, had improved since the delegation of water management to private companies.

    In Uganda, water sector reforms included more funding from the government and better management of the National Water and Sewerage Corporation - a privately managed but publicly owned water company responsible for the 15 largest cities in the country. According to Water Aid, in just five years after the reforms, it had transformed from being a highly inefficient, underperforming and loss-making body to a healthy and financially sustainable public corporation. Service coverage grew from 48 to 74 percent between 1998 and 2010. The same period witnessed household connections increase from 53,000 to 246,259.

    Still, corruption has been a challenge.

    “In a study of corruption in Uganda’s water sector, private contractors estimated the average bribe related to a contract award to be 10 percent [of the total cost]. The same study showed that 46 per cent of all urban water consumers had paid extra money for connections,” said WGF’s Jacobson.

    Kenya, on the other hand, abandoned plans to open up Nairobi’s water supply to private companies, fearing it would inflate water prices.

    In 2008, Mali experienced anti-privatization protests that left one person dead and five others injured in the capital, Bamako.

    In Ghana, water tariffs increased by 80 percent after privatization, and a third of the country’s population still has no access to safe and clean water.

    “Experience suggests that to make private sector engagement work, effective government regulatory powers are required,” says WGF.

    Ending corruption in the sector, experts like WGF’s Jacobson say, would require diagnosing the effectiveness of anticorruption interventions, creating legal and financial reforms, and building public sector capacity.


    In Africa, corruption dirties the water
  • African migrants pay high prices to send money home

    New data from the World Bank has revealed that African migrants pay more to send money home to their families than any other migrant group in the world. 

    While South Asians pay an average of US$6 for every $100 they send home, Africans often pay more than twice that - and in South Africa, which has the highest remittance costs on the continent, nearly 21 percent of money set aside for family members back home is spent on getting it there.

    With an estimated 120 million Africans depending on remittances from family members abroad for their survival, health and education, the World Bank argues that high transaction costs are cutting into the impact remittances can have on poverty levels. 

    To address this, the Bank is partnering with the African Union Commission and member states to establish the African Institute for Remittances, which will work towards lowering the transaction costs of remittances to and within Africa. It will also leverage the potential of remittances to influence economic and social development. 

    “The World Bank’s approach supports regulatory and policy reforms that promote transparency and market competition and the creation of an enabling environment that promotes innovative payment and remittance products,” said Marco Nicoli, a finance analyst at the Bank who specializes in remittances.

    Costly and difficult

    Owen Maromo, a 33-year-old farmworker who lives in De Doorns, a grape-growing region in South Africa’s Western Cape Province, told IRIN that his family in Zimbabwe relies on the money he sends home every month. 

    “I’ve got a house there and I need to pay rent. I’m also taking care of my youngest brother - since my mum died four years ago - and my wife’s family.

    “Almost every Zimbabwean here is budgeting to send money back home,” he added. “If they could, they would send money home on a weekly basis.”

    In a 2012 report by the Cape Town-based NGO People Against Suffering Oppression and Poverty (PASSOP), interviews with 350 Zimbabwean migrants revealed some of the reasons sending money home from South Africa is both costly and difficult.

    "There are a lot of people whose money just disappears. Almost on a daily basis, you hear those stories" 

    A key impediment is the stringent regulatory framework that governs cross-border transfers from South Africa. Exchange control legislation, for example, requires money transfer operators (MTOs) to partner with a bank. According to PASSOP, this has had the effect of stifling competition that would likely reduce transaction costs.  

    Legislation intending to counter money laundering and terrorist financing requires that customers provide proof of residence and proof of the source of their funds before they can access financial services. This effectively excludes the many migrants living in informal settlements and those who are paid in cash. 

    PASSOP found that even among migrants who do have access to banks and MTOs like Western Union and MoneyGram, many lack the financial literacy to make use of them. 

    “Some have just come from rural areas in Zimbabwe, so it takes time for them to know about such things,” said Maromo, adding that lack of documentation was another major obstacle. “If you’re undocumented, you can’t go through the banks.”

    Three-quarters of the Zimbabwean migrants interviewed by PASSOP relied instead on “informal” remittance channels, such as giving money or goods to bus drivers, friends or agents to send home. This is often not much cheaper than using banks or MTOs, and it is significantly riskier. Of the respondents who used such methods, 84 percent reported negative experiences, including theft of their money, loss or destruction of their goods and long delays in remittances reaching intended recipients. 

    Maromo relayed his own experience sending money home through an agent who charged a 15 percent commission to channel the money through his South African bank account before handing it over to Maromo’s relatives in Zimbabwe. “Some time ago, I nearly lost 2,000 rand ($225) because I deposited it in [the agent’s] account and he was saying he didn’t have it and giving excuses. In the end, we got the money, but it cost us nearly 1,000 rand ($113) in airtime calling Zimbabwe,” he said.

    “Some are using bus drivers or those people who are going home, and you have to trust them because you’re desperate, but there can be a lot of problems,” he added. “There are a lot of people whose money just disappears. Almost on a daily basis, you hear those stories.”

    Lowering transaction fees

    Now, Maromo uses a UK-based online transfer service called, which is popular with many Zimbabweans living overseas. The proof of residence and source of funds requirements are the same as for traditional MTOs, but the site charges 10 percent on transfers from South Africa to Zimbabwe - less than most banks. 

    The South African Reserve Bank and the treasury have committed to bringing the cost of remittances down to 5 percent by relaxing regulations for smaller money transfers, negotiating with regulators in the Southern African Development Community on exchange control regulations, and removing the requirement that MTOs partner with banks.

    However, at the time of writing, the Reserve Bank has not yet responded to questions from IRIN about how these changes will be implemented and within what timeframe.

    Rob Burrell, director of, said achieving the 5 percent target would be tough considering the numerous costs that MTOs have to cover, including fees paid to the companies that collect and pay out the money, the cost of supporting transactions through a call centre, and licensing and reporting requirements. “We would need everyone pulling together,” he said.

    Burrell noted that less stringent laws governing MTOs in the UK mean more competition but much weaker anti-money laundering controls. To operate in South Africa, has to comply with the regulation that they partner with a local banking license holder.

    “In the UK, it’s easier to obtain your license,"he told IRIN. "There are 4,000 [MTOs operating in the UK] compared to 12 in South Africa, but the downside is that it’s very difficult to police them all.” 


    Africa's high remittance costs
  • Mali a “wake-up call” for drug trafficking, says think tank

    At the launch of a Ghana-based Commission on the Impact of Drug-Trafficking on Governance, Security and Development in West Africa, its chair, former Nigerian President Olusegun Obasanjo, said the situation in Mali should serve as a “wake-up call” to the perils of allowing organized crime to escalate out of control.

    He described the country’s north as a “den of drug trafficking, extremism and criminality”.

    Several research groups have reported that traffickers have linked up with extremist groups in the Sahel region, who use the profits to purchase weapons and fund radical activities. Al-Qaeda in the Islamic Maghreb (AQIM) has partially funded its activities in northern Mali over the past decade through profits from drug and cigarette trafficking and hostage ransoms, according to a 2012 report by the African Center for Strategic Studies.

    Analysts estimate around 60 tons of cocaine are trafficked through West Africa each year, while the UN Office on Drugs and Crime (UNODC) estimates 400kg of heroin was trafficked through the region in 2011. The trade brings in an estimated US$900 million per year to criminal networks, says UNODC.

    Some 15 percent of the cigarettes smoked in the region are bought on the black market and trafficked through West Africa, according to UNODC. AQIM and to some extent splinter-group Movement for Oneness and Jihad in West Africa (MUJAO) have been taxing traffickers in return for safeguarding their passage.

    “Organized criminal networks are deeply involved in the trafficking. Experience elsewhere in the world suggests that these groups will try to infiltrate political, security and financial institutions to secure their profits,” former UN Secretary-General Kofi Annan told the audience at the launch of the Commission in Ghana’s capital last week.

    Over the last decade many West African states have made gains to consolidate peace and economic growth: the region is set to provide the US with 25 percent of its oil needs in 2015 - but drug-trafficking threatens this progress, said Annan.

    Most of the cocaine is transported from South America to Europe, using air and sea routes; while opiates tend to come from Pakistan and Afghanistan.

    Drugs are also increasingly being manufactured in the region. The police recently discovered methamphetamine laboratories in Nigeria, according to UNODC.

    Growing drug dependency

    There are now as many as 2.3 million cocaine users in West and Central Africa, and methamphetamine and heroin use are on the rise, UNODC reported in 2012. “The evidence points to a growing problem of dependency that needs urgent attention in our region,” Obasanjo said.

    Annan pointed out: “West Africa initially was seen as a transit point but no country remains a transit point for long. The population begins to use it.”

    The 10-member Commission intends to raise awareness of the impact of the drug trade, advise political leaders, and develop policy recommendations to help leaders deal with drug-trafficking.

    West Africa is an ideal environment for drug traffickers with its extensive porous borders, weak and easily corruptible institutions, and pre-existing criminal networks. In these poor nations it is easy to buy off low-paid and disenchanted officials and security personnel: “The police are bribed. Now, in a fairly poor African country, US$100 to a police constable is a lot of money. All he has to do is turn his eyes,” said Obasanjo.

    He added that criminal networks can easily smuggle goods through the region, buying off officials and security personnel at borders, as they move through remote regions of the Sahel and the Sahara desert.

    Fluid networks

    Criminal trafficking networks are international and very mobile, which makes it difficult to crack down on them, says the UNODC. Local and foreign criminal networks with access to massive resources work together to transport drugs through the region, adapting their operations in response to law enforcement efforts, according to an April 2012 joint report by the Economic Community of West African States (ECOWAS), the Center on International Cooperation, the Kofi Annan Foundation and the Kofi Annan International Peacekeeping Training Centre.

    “West African organized criminal networks operate cells worldwide to facilitate the supply of goods, with Diaspora communities playing important roles (e.g. Nigerian Diaspora in Brazil). Like criminal groups elsewhere, they infiltrate or threaten political elites and dispirited public servants to protect and expand their business,” the report said.

    As the myriad abandoned construction sites in many West African states make clear, traffickers also extensively operate fronts to launder their profits, creating “shell companies” in the construction and mining sectors, as well as rental car companies.

    The government and security forces of Guinea-Bissau have already largely been taken over by drug trafficking networks, earning it the moniker of “narco-state.”

    AQIM members reportedly met Colombian drug lords in Guinea-Bissau, according to a 2010 report by France-based research group Sahel Intelligence. While the trade allegedly continues to flourish in Guinea-Bissau, networks have also gradually moved along the coast and inland through the Sahel, Annan said. “We didn’t act early enough when the problem started in Guinea-Bissau. That was the entry point and it’s now spread along the coast - and through the Sahel to Europe and by ship and by plane,” Annan told reporters. Other initiatives are way to try to quell the impact of drug-trafficking in the region, including an ECOWAS plan to address the challenges of trafficking.

    UNODC recently teamed up with the World Customs Organization to improve communications between police and airports.

    The Commission will deliver a report and submit policy recommendations to regional leaders by the end of 2013.


    Mali “wake-up call” for drug trafficking
  • Staples, not export crops, key to tackling Africa’s poverty – report

    Africa could reduce its poverty levels faster by focusing more on the production of staples rather than export crops, according to a study by the International Food Policy Research Institute (IFPRI).

    Authors of the study, conducted in 10 countries south of the Sahara, noted, “One important finding is that producing more staple crops, such as maize, pulses and roots, and more livestock products tends to reduce poverty further than producing more export crops such as coffee or cut flowers.”

    According to the study, while more public resources would be required to generate more agricultural growth, “such public investment in staple sectors is probably cost effective”.

    The authors argued that growth in the staple sector was more likely to benefit the poor than growth in the agricultural export sector.

    Enoch Mwani, an agricultural economist at the University of Nairobi, concurred. “The agricultural export sector is generally associated with large corporations, but the poor rely predominantly on staples to survive.”

    Mwani added that growth in staples had the effect of not only reducing poverty but also ensuring food security.

    “[Governments that] invest in staples have the opportunity to increase food availability and, at the same time, create wealth for smallholders,” Mwani told IRIN.

    To spur development in sub-Saharan Africa, the study’s policy conclusions call for a focus on accelerating agricultural growth; promoting growth in large agricultural subsectors; supporting growth across several agricultural subsectors; and promoting growth in subsectors with strong linkages to the overall economy and the poor.


    Staple crops key to aiding Africa’s poor
  • How we live and die

    We all know we are going to die, but how and when it happens depends largely on who we are and where we live. We think we know the major risks - perhaps malaria or AIDS-related diseases in Africa, or stroke, cancer and heart disease in North America and Western Europe. But, in fact, patterns of mortality and morbidity are rapidly changing around the world.

    This was the revelation of more than five years of data collection and analysis, which culminated in the recent publication of the Global Burden of Disease Study 2010. Led by the University of Washington’s Institute for Health Metrics and Evaluation (IHME), the study involved 486 authors from 50 countries.

    Peter Piot, the director of London’s School of Hygiene and Tropical Medicine, said the speed of change has taken researchers by surprise. “It’s going much faster than I think that we all thought. But there is also enormous diversity.”

    Good and bad news

    The study reveals that people can expect to live longer - in some cases, dramatically longer. Overall life expectancy worldwide has increased by more than a decade since 1970. The Indian Ocean island nation of Maldives has shown the most striking improvement: a woman there in the 1970s lived on average to 51; now the average lifespan increased by three decades.

    But there were also disappointments. The big one, said Chris Murray, IHME’s director, is that health gains have been uneven.

    “These rapid transformations in health don’t seem to translate into a change in the leading causes of [disease] burden in sub-Saharan Africa. We have quantified considerable progress there. Child mortality rates are down quite substantially. There’s progress - especially since 2004 - in reducing HIV-related death. There’s progress in reducing malaria due to the scale-up of bed nets and artemisinin-combination therapy. But despite that progress, 65 to 70 percent of the burden of ill-health is still related to MDGs [Millennium Development Goals] four, five and six,” he said, referring to the MDGs to significantly reduce child mortality, improve maternal health, and combat HIV, malaria and other diseases by 2015.

    “For me,” Piot told IRIN, “the key is: let’s not assume that the MDGs, as they are now, will all be achieved by 2015, that we can drop that and then move on with a completely blank sheet. That would be a disaster. And that’s what’s in the pipeline, I am sorry to say.”

    Changing trends

    The researchers noted a shift away from infectious diseases as a cause of death towards non-communicable diseases such as cancer, stroke and heart disease - often called “lifestyle” diseases. Among communicable diseases, only AIDS and, to a lesser extent, malaria have increased since 1990, primarily in sub-Saharan Africa.

    Now only 25 percent of deaths globally are due to infectious diseases and maternal, neonatal and nutritional causes. More than 65 percent are due to non-communicable conditions, and just under 10 percent are related to injuries, the bulk of them happening on increasingly deadly roads in the world’s poorest places.

    Irene Agyepong, from University of Ghana’s public health school, said countries in Africa are increasingly facing the dual burden of fighting “old” as well as “new” diseases.

    “Two years ago, we looked at the data from Greater Accra [the capital area]… which is about 90 percent urban now. And we realized that hypertension had moved to number two among the common causes of outpatient attendance and was a leading cause of death, which is very different from the rest of the country,” she said. “And I was discussing with a colleague that we should start research into cardiovascular disease in low- and middle-income countries, and he was still saying, ‘Why on earth would you do that? It’s not a problem.’”


    Data-keeping has surfaced as one of the biggest challenges countries face in setting targets to reduce non-communicable diseases.

    Only about two-thirds of the world’s countries have “vital” registration systems that record births and deaths sufficiently to estimate death rates from various causes, according to World Health Organization (WHO). WHO noted in March that 74 countries lacked data on cause of death, while another 81 countries had only lower-quality data.

    The IHME-led team said that while researchers have, until now, only occasionally conducted such global disease burden studies, they hope to keep the database updated and freely available. They have also provided a set of interactive tools that present information by different categories, including region and population segment. They plan to add a country filter next year.


    How we live and die
  • Defining piracy in the Gulf of Guinea

    In July last year President Boni Yayi of Benin sent a worried letter to the UN secretary-general. His country was being threatened by the activities of pirates, who were scaring shipping away from the ports on which his country's revenues depend. He wanted international help of the kind which had been deployed against piracy off the coast of Somalia.

    His letter put the issue of piracy off the West African coast onto the world agenda. The attacks continue and still cluster in the vicinity of Benin and its neighbour, Nigeria, but despite UN missions and a Security Council debate, the international community is still unsure of the best way to proceed.

    On 6 December Coventry University organized a conference on Maritime Security in the Gulf of Guinea, in collaboration with London's Chatham House. One thing which emerged very clearly from the sessions was that what is being called piracy in this area is very different from piracy off the East African coast, and the kind of international naval deployment used against Somali pirates is unlikely to help.

    In fact Chris Trelawny, deputy director of the Maritime Safety Division at the International Maritime Organization (IMO), suggested that most of what was going on in West African waters was not really piracy at all, within the meaning of the international conventions. "Piracy is defined as happening `outside the jurisdiction of any state', so outside 12 miles is piracy. If it's inside 12 miles we classify that as armed robbery against ships. The difference is jurisdiction. Piracy is a universal crime and states have an obligation to intervene. Inside 12 miles it is the coastal state's responsibility."

    Of the attacks which have been reported to IMO over the past 10 years, only a minority, 108, have happened in international waters: 170 were within territorial waters and 270 actually took place in port. So these are crimes taking place within national jurisdiction, and even though some of the coastal states of West Africa have states and judicial systems which are quite weak, there is no void of authority, like that in Somalia.

    Few prosecutions

    Using an international naval task force to address the problem is inappropriate in other ways too. Navies can be very good at deterring pirates, or chasing them and recovering stolen weapons and cargo, but they are not designed or trained to collect evidence and process criminals for prosecution.

    One of the speakers at Chatham House was Tony Attah from Shell Nigeria, a company which has suffered severely from maritime crime, sometimes losing whole cargoes of crude oil to pirates. Nigeria has a joint military task force which is now mandated to tackle oil theft but Attah is frustrated by the results. "We are aware that over 1,000 illegal refineries have been destroyed through the efforts of the navy, and a number of tankers full of stolen crude have been seized in high profile raids, but despite the increased focus to date, we are not aware of a single thief being prosecuted or convicted. The big barons behind this criminality walk free."

    The oil industry, much of it offshore, is one of the main lures for maritime criminals in the area. And, says Attah, this is not petty crime. "I can tell you this is a well-financed criminal phenomenon, a parallel industry, with a well-developed supply chain and growing sophistication. It includes trained engineers who weld valves to high pressure pipelines, boatyards which construct and supply barges."

    Oil is also the reason why the issue is of wider international significance. The region supplies around 40 percent of Europe's oil and 29 percent of that consumed by the USA. Keeping these shipping lanes open and safe is vital for world supply. The outside world is ready to offer some help - both the British Navy and the US Africa Command were represented at the meeting. Both have offered training and capacity building to West African navies and coast guards.

    For these national forces to work together is clearly important because the criminals are so mobile. One speaker likened fighting piracy in the region to sitting on a balloon - push down on one side and it pops up at the other; push on the other side and it pops up somewhere else. Joint military patrols by the Nigerian and Beninois navies reduced attacks in their own waters, but moved the pirates' attention to Togo and Côte d'Ivoire.

    So far that has been the only joint action; apart from that, regional cooperation has mostly involved meetings and seminars, held by regional bodies.

    Information gap

    One of the major gaps is a lack of information, highlighted at the meeting by Lt-Cmdr Stephen Anderson of the UK's Royal Navy whose ship, the Dauntless, recently returned from a patrol in the Gulf of Guinea, and who had clearly been very struck by the near impossibility of finding out which ships were meant to be there, and which were suspect vessels.

    There is a sense at the moment that the region and its international allies are still feeling their way. Piracy off the west coast of Africa is not yet at the same level as that that off Somalia to the east, but there is a clear concern that it could escalate.

    The deputy executive secretary of the Gulf of Guinea Commission, Ambassador Florentina Ukonga, addressed a heartfelt appeal to all those concerned. "With the right combination of efforts. to achieve a common legal framework for the arrest and prosecution of criminals, adequate financial investment and capacity building - piracy can be reduced to a bare minimum.


    Defining piracy in the Gulf of Guinea
  • African IDP Convention comes into force

    The African Union Convention for the Protection and Assistance of Internally Displaced Persons (IDPs) 2009, also known as the Kampala Convention, came into force on 6 December; it is the world’s first legally binding instrument to cater specifically to people displaced within their own countries.

    Adopted at an AU summit in the Ugandan capital, Kampala, the Convention required ratification by 15 member countries before it could enter into force; Swaziland became the 15th country to do so on 12 November, joining Benin, Burkina Faso, Central African Republic, Chad, Gabon, Gambia, Guinea-Bissau, Lesotho, Niger, Nigeria, Sierra Leone, Togo, Uganda and Zambia. At least 37 AU members have also signed the Convention but have yet to ratify it.

    Among other things, the Convention aims to "establish a legal framework for preventing internal displacement, and protecting and assisting internally displaced persons in Africa".

    UN High Commissioner for Refugees Antonio Guterres hailed the development as "historic" and said in a statement that the Convention "puts Africa in a leading position when it comes to having a legal framework for protecting and helping the internally displaced".

    Stephen Oola, a transitional justice and governance analyst at Uganda's Makerere University Refugee Law Project, noted that the most important parts of the Convention were the clauses relating to the prevention of internal displacement. "The principle requiring the prevention of IDPs is absolutely necessary and should be the guiding principle for all state and non-state actors implementing the Convention," he said.

    Just the beginning

    Oola also stressed the need for the letter of the law to be translated into practice.

    "In Uganda, we have had an IDP policy since 2004, but in many cases we find that the government still seems ill-prepared to deal with displacement," he said. "The existence of a law is rarely the conclusion of a policy... It will be important for this continental commitment to be matched by action on the ground for people who, for one reason or another, find themselves displaced," he said.

    Africa has 9.7 million IDPs, according to the UN Refugee Agency, UNHCR. The Democratic Republic of Congo, Somalia and Sudan collectively have more than five million IDPs.

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    Noting that the situation of IDPs can affect the stability of states, UN Special Rapporteur on the Human Rights of Internally Displaced Persons Chakola Beyani said the Convention could "contribute to stabilizing displaced populations through the specific obligations it sets out to states and other actors, such as obligations relating to humanitarian assistance, compensation and assistance in finding lasting solutions to displacement as well as accessing the full range of their human rights".

    "The unique 'added value' of this Convention stems from how comprehensive it is and the manner in which it addresses many of the key challenges of our times and, indeed, of Africa," he said in a statement. "If implemented well, it can help states and the African Union address both current and potential future internal displacement related not only to conflict, but also natural disasters and other effects of climate change, development, and even megatrends such as population growth and rapid urbanization."

    The International Displacement Monitoring Centre (IDMC) noted that, while the Convention signalled an important step in addressing the plight of IDPs, many countries were not legally bound by it.

    "The countries which have not yet adopted the Convention must do so, as a legal framework is the very basis of ensuring the rights and well-being of people forced to flee inside their home country," Sebastian Albuja, head of IDMC's Africa department, said in a statement.

    According to Nuur Sheekh, board member of the Kenya-based Internal Displacement Policy and Advocacy Centre, some states expressed reservations about signing the Convention because "the issue of displacement is highly politicized, and some states saw it as a criticism of their human rights and governance records". He noted, however, that the Convention would have an influence, even on those countries that have not signed or ratified it.

    "The AU will now also be able to use the Convention for advocacy, to encourage member states - even those who have not ratified it - to implement its principles... Kenya, for instance has not signed it but has developed an IDP policy that borrows heavily from the Kampala Convention," he told IRIN. "States now need to domesticate the Convention and develop IDP policies that reach from the central government to all lower levels of government so that the Convention can work in practice."


    African IDP Convention comes into force
  • Breaking out of the cold chain

    Health workers currently immunizing thousands of children and young adults against Meningitis A in Benin are currently doing so without having to spend days preparing ice packs and sourcing generators and fridges to load on trucks because the vaccine has now won approval for being kept at up to 40 degrees Celsius for as long as four days.

    Before, like almost all vaccines, the Meningitis A vaccine (marketed in Africa as MenAfricVac) was only licensed for use if kept at temperatures of 2-8 degrees Celsius.

    The breakthrough follows years of rigorous testing of the effect of heat on the vaccine by the regulator Drugs Controller General of India, Health Canada, and the World Health Organization (WHO) Vaccines pre-qualification programme.

    As a result, very remote populations will access the vaccine more easily, the logistics of vaccine campaigns will be simpler, and vaccine campaign costs will drop both for partners and for national governments, said Michel Zaffran, coordinator of WHO’s Expanded Programme on Immunization (EPI), and Marie-Pierre Preziosi, director of the meningitis Vaccine Project, a partnership between international NGO PATH and WHO.

    Costs will not drop significantly immediately, but will diminish as more vaccines are relicensed, says WHO. Cost implication studies are under way in northern Benin and Chad.

    While cold chain limitations do not tend to limit coverage, they do overburden health workers, says WHO.

    Even industrialized country vaccine campaigns have trouble sticking to the cold chain, and each year thousands of vaccines are thrown away due to cold chain failure, even if the vaccine might still have been unaffected, according to WHO.

    “This is a breakthrough,” said Zaffran. “It is the first vaccination ever to be licensed for use in a developing country with the flexibility to take us out of the rigid temperature structure. It is a great simplification of logistics. And it opens the door for other manufacturers to follow suit.”

    Why so long?

    But the vaccine is nothing new - merely the license has changed following analysis of years of data on the vaccine’s stability - that is, how well it can withstand temperature rises and other conditions.

    “The potential for some vaccines to remain safely outside the cold chain for short periods of time has been widely known for over 20 years,” said Zaffran in a recent communiqué. “But this is the first time a vaccine intended for use in Africa has been tested and submitted to regulatory review and approved for this type of use.”

    Meningitis belt in Africa (<a href="" target="_blank"><strong><font color=#006699>See larger version of map</strong></a>)

    Meningitis belt in Africa (<a href="" target="_blank"><strong><font color=#006699>See larger version of map</strong></a>)...
    Wednesday, February 24, 2010
    Breaking out of the cold chain
    Meningitis belt in Africa (<a href="" target="_blank"><strong><font color=#006699>See larger version of map</strong></a>)...

    Photo: ReliefWeb
    The Meningitis Belt

    It took decades to get here because agencies got stuck in a mindset, said Zaffran. The EPI was set up in the 1970s to immunize as many children against diseases as quickly as possible, and put in place simple rigid rules to avoid risk: one of which was to keep vaccines cold. “It was quite difficult to move away from this mentality,” said Zaffran.

    Regulators and manufacturers are “very conservative in order to protect the population,” said Preziosi. “It took a while for all the documentation to be gathered to convince them to go ahead.”

    Strict controls remain: “This is not a “green light to do anything with a vaccine - it still needs to be kept… at no more than 40 degrees, for any more than four days," stressed Zaffran.

    Hepatitis B next?

    “The momentum is there. I am quite confident that within the next year or two, we’ll have one or two more re-licensed in this way,” he said.

    Analysis on the heat stability of Hepatitis B and HPV (human papillomavirus) vaccines is under way; next on the list are yellow fever, rotavirus and pneumococcal disease.

    Even the oral polio vaccine - one of the most heat-sensitive vaccines - was shown to be stable when the cold chain broke down in a part of Chad, according to a recent study though WHO was emphatic that rather than licensing the vaccine it will gradually be phased out as progress towards eradication inches along.

    Meningitis progress

    The MenAfricVac, which costs just under 50 US cents per dose, was designed for use in the 26 countries that span the African meningitis belt, from Senegal to Ethiopia.

    Some 100 million people aged 1-29 across 10 countries have been vaccinated thus far; a further 16 countries are planned between now and 2016.

    Early results have been very positive: Burkina Faso has had the lowest level of epidemic meningitis in 15 years, and the campaign is achieving “herd immunity” - that is, those either too old or too young to have received the vaccine have also been shown to be clear of the bacteria.

    Meningitis A could be eliminated in the meningitis belt if the mass campaign continues, says Preziosi, and if governments then incorporate it in their routine immunization programmes.

    But more funding beyond the US$160 million from the GAVI Alliance, and contributions from national governments, will be needed to complete the campaign, she warns.


    Breaking out of the cold chain
  • Misery of “prayer camps” for mentally ill

    Doris Appiah, 57, has bipolar disorder. In her early twenties, she was sent to an overcrowded psychiatric hospital followed by a “prayer camp” to be treated. She stayed there for five years, at times tied to a wall or forced to fast. Her story is mirrored by thousands of mentally ill people across Ghana, according to a 2 October Human Rights Watch (HRW) report entitled Like a Death Sentence.

    The government is trying to update the country’s mental health care laws, starting with the passing of the 2012 Mental Health Act. The act is supposed to improve access to mental health services and prevent abuse. But HRW says the law does not go far enough as it only addresses the formal health sector rather than community-based mental healthcare needs.

    Patients with mental health problems are often kept against their will in overcrowded and unsanitary psychiatric institutions.

    Ghana has only three public psychiatric hospitals (all of them in the south), 12 practising psychiatrists, and 600 psychiatric nurses. In one ward of Accra Psychiatric Hospital in the capital, there are just 26 functional beds for 205 in-patients, according to HRW. Nurses, lacking cleaning equipment, “instructed patients to clean the wards and toilets, including removing other patients’ faeces without gloves”, said the researchers.

    Without enough staff to properly restrain aggressive patients, staff routinely turn to violence, patients told HRW. Patients reported physical abuse in the form of beatings, forced seclusion and involuntary electro-shock therapy.

    One 25-year-old pregnant woman told a group of HRW researchers who visited three institutions and eight prayer camps earlier this year, that while kept in a seclusion room for 12 hours she was beaten by nurses.

    Health Ministry spokesman Daniel Osman said he acknowledges that Ghana’s psychiatric hospitals are overcrowded, understaffed, and difficult to access for many people in need, but said progress was being made. “We are making an effort to decentralize [the system] so every regional hospital has a psychiatric unit,” he told IRIN.

    ''You think you are human, but people no longer think you are human''

    The World Health Organization has estimated some 2.8 million people have mental disabilities in Ghana, 650,000 of them severe. The most common problems are schizophrenia, bipolar disorder and major depression, Akwasi Osei, director of Accra Psychiatric Hospital, told HRW. Less common, but prevalent, are drug-related psychosis and epilepsy.

    Community stigma

    Families send their relatives to such institutions when a mental health crisis becomes acute and often because they feel they have few alternatives: There is little-to-no community care for mental illness in Ghana.

    “It is so stigmatizing even to be seen entering the gate of a psychiatric hospital. People will brand you," said Medi Ssengooba, a disability rights research fellow with HRW in New York. “If services were provided in the community, people would go in and seek them freely,” he said, acknowledging it would take time for attitudes to change.

    Mental disability in Ghana is widely considered to be caused by evil spirits or demons. When “orthodox” psychiatric treatment does not work, some resort to prayer camps which enact so-called spiritual healing.

    Bondage and fasting

    In reality, many residents of prayer camps face severe abuse. Aggressive residents are chained up, according to Ssengooba. “Almost everyone we met… was chained to trees or to walls,” including children as young as nine.

    Residents are regularly denied food and drink for a three-day period or required to fast 12 hours a day for up to 40 days, as this is thought to rid the body of evil spirits. “I’m really, really hungry and they won’t feed me. I don’t understand… Why can I not eat? They give me porridge at night, but that’s not enough food,” a woman identified as Afia at Mount Horeb Prayer camp in Ghana’s Eastern region told researchers.

    Doris Appiah spent 19 years in prayer camps and psychiatric hospitals before being discharged in 1989. “They kept moving me because they were not seeing results, and they were not seeing results because the right thing was not being done,” she told IRIN.

    “You think you are human, but people no longer think you are human,” she added.


    Shantha Rau Barriga/Human Rights Watch
    At Heavenly Ministries Spiritual Revival and Healing Center, some people with presumed mental disabilities lived in buildings with cubicles for each resident and were chained to walls. They could not leave the cubicles without permission of the staff at t
    Tuesday, October 2, 2012
    Rethinking mental health in Africa
    At Heavenly Ministries Spiritual Revival and Healing Center, some people with presumed mental disabilities lived in buildings with cubicles for each resident and were chained to walls. They could not leave the cubicles without permission of the staff at t

    Photo: Shantha Rau Barriga/Human Rights Watch
    At Heavenly Ministries Spiritual Revival and Healing Center, residents cannot leave their cubicles without permission of the staff

    Residents of both hospitals and prayer camps are often kept against their will”: Prayer camp leaders say they must wait for messages from God before releasing residents, said Ssengooba.

    The Ministry of Health’s Osman said the government had little oversight of prayer camps, as they are run by churches.


    The situation is improving slowly. Thanks to the disabilities act, people can now challenge their detention in institutions. Access to appropriate medication has also improved over the past 30 years, and several advocacy organizations now lobby to improve the quality of services for the mentally ill.

    Appiah has learned to manage her illness with the right medicine and the help of international NGO Basic Needs. She now works as the treasurer of the Mental Health Society of Ghana.

    But parts of the act still transgress the 2006 Convention on the Rights of Persons with Disabilities (which Ghana has ratified), as it still enables forced admission and treatment in psychiatric hospitals. And there is not enough emphasis on community-based care (providing the mentally ill with housing and health care, for instance) or on monitoring the quality of hospital care, warns HRW.

    If quality monitoring worked, some institutions would be forced to cease taking on patients altogether. “If you don’t have the means to house them [mentally ill patients], or to feed them - if the only means you have to constrain an aggressive person is to chain them, that person should not be a service provider,” Ssengooba told IRIN.


    Misery of “prayer camps” for mentally ill

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