bmj.com Rapid Responses for Volmink et al., 330 (7493) 684-685

Rapid Responses to:

EDITORIALS:
Jimmy Volmink, Lola Dare, and Jocalyn Clark
A theme issue "by, for, and about" Africa
BMJ 2005; 330: 684-685 [Full text]

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Rapid Responses published:

What to Bring out from Africa?: Matiram Pun (25 March 2005)

A call to answer: Anayo Fidelis Akunne (26 March 2005)

Are hospital partnerships part of the answer?: Caris Grimes (27 March 2005)

Submit papers to submit.bmj.com: Jocalyn Clark (29 March 2005)

Something is missing: Barry Pless (31 March 2005)

What is not mentioned, is not measured: Adnan Hyder (3 April 2005)

The Challenges of Health Care Delivery in Developing Countries: Victor Y Ameh, Abdu Opaluwa, Staff Grade, General Surgery, Queen Elizabeth Hospital, Kings Lynn. PE30 4EJ (8 April 2005)

Injuries in African children-a quick review: Ntambwe Malangu, Helen A Lewis, Senior Lecturer, University of Limpopo (14 April 2005)

Controversies surrounding circumcision: Botswana: Dr. Rajesh Chauhan. MBBS, DFM, FCGP, ADHA, FISCD (2 May 2005)

Africa Theme Issue: DYING OF BREAST CANCER IN AFRICA: Isaac D Gukas (4 May 2005)

Overcoming the obstacles for effective international collaborative research work in Africa: Experience with collaborative work between Nigeria and UK: Isaac D. Gukas, Barbara A. Jennings -Senior Lecturer, Ian Harvey -Professor of epidemiology, Samuel J. Leinster - Professor of medical education, School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK (5 May 2005)

Re: Injuries in African children: we need more publications: Isaac D. Gukas (5 May 2005)

HIV/AIDS in Africa: Is it A, B, C or D? The answer from Africa should be 'A to D' for now and hope for more effective 'A to C': Aceme Nyika (27 June 2005)

Maternal mortality in rural Burkina Faso: Issiaka Sombie, Nicolas Meda, Mich�le Dramaix-Wilmet , Odette Ky-Zerbo, SimonCousens (13 July 2005)

Re: Call to governments to boost innovation for neglected diseases: Bernard Pecoul (4 August 2005)

Gaining Public Support to Reduce the 10/90 Gap: A Canadian Example: Bernadette Stringer, Ted Haines and Carroll Iwasiw (9 August 2005)

Palliative Care in the era of Antiretroviral treatment: Richard Harding, Catherine Senyimba, Edmund Mwebesa, Siobhan Kennelly, Karen Frame (18 August 2005)

Advantages of Reversing African Brain Drain: Joseph N Ana, 20 Eta Agbor Road, Calabar, Nigeria (18 August 2005)

Cancer hidden in the shadow of AIDS: It's time to wake up to the toll of cancer in Africa: Scott A Murray, Elizabeth Grant, Faith Mwangi-Powell (20 August 2005)

Preventing mother-to-child transmission of HIV: have we prematurely discarded vaginal disinfection?: Charles Shey Wiysonge, Muki Shehu Shey (25 August 2005)

�Flashblood� and HIV risk among IDUs in Dar es Salaam, Tanzania: Sheryl A. McCurdy, Mark. L. Williams, Michael W. Ross, Gad P. Kilonzo, and M.T. Leshabari (25 August 2005)

Diabetes in Africa: addressing the challenge: David Beran, John S. Yudkin (1 September 2005)

Implementation of a program for the prevention of mother-to-child transmission of HIV in a ugandan hospital over 5 years : challenges, improvements and lessons learned: Marina Giuliano, Michele Magoni, Luciana Bassani, Pius Okong, Praxedes Kituka Namaganda, and Saul Onyango (5 September 2005)

Capacity building in collaborative research between developed and developing countries: Prem K. Mony, Mario Vaz, Anura Kurpad (16 September 2005)

Africas problems easier to solve: John P Heptonstall (17 September 2005)

What to Bring out from Africa? 25 March 2005

Matiram Pun,
Medical Student
Institute of Medicine, Kathmandu, Nepal
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Re: What to Bring out from Africa?

Africa needs to bring out the all the dimensions of the health problems that it suffers with and of course the proposed solutions for them in this wonderful forum created by the BMJ. Definitely the challenges and solutions are complex, deeply rooted in political, socioeconomic, and cultural issues1. They badly need to be addressed, for the better health status to come out, which may take decades. The developing world Asia, Africa and South America are having the changing trend of disease pattern over the years. The diseases due to poor sanitation, infections and re- emergence of the infectious diseases are there but there are increasing risk factors for the cardiovascular and other non communicable diseases e.g. poor diets, inactivity, tobacco use, risky health behaviours etc2. However our prime objective should be to cover the burning problems e.g. Diarrhoea, Acute Respiratory Tract Infections, Malaria, HIV/AIDS and TB, Kala azar, Leashmaniasis etc. that lead to the death toll of millions per year around the developing world. Hopefully, the theme issue covers all.
Matiram Pun Institute of Medicine Kathmandu, Nepal
Competing interests: None declared

A call to answer 26 March 2005

Anayo Fidelis Akunne,
Doctoral Candidate
Tropical Hygiene and Public Health, Medical School, University of Heidelberg, Germany
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Re: A call to answer

Dear Editor,
Your theme issue on Africa1 is definitely a welcomed opportunity that should not be missed by those who are concerned about dealing with the numerous challenges of the magnificent Continent. The millennium development goals may be failing to reach their targets in a way that will benefit the poor Africans, Blair�s commission for Africa may be under criticism, and all what not. However, this issue provides the chance for making available the information for evaluation.
As rightly mentioned in your editorial, Africa is vast in culture and regional diversity. About 27 out of the 48 countries in sub-Saharan Africa do not have English as an official language2 and it will be good to have papers from researchers from non-English speaking regions. This encourages having a diverse mix and representative information on the state of medical research in the Continent.
The issue on availability of essential medicines is currently burning. Many African countries depend on India for supply of cheap and effective generic drugs and we cannot wait to read on the accessibility of medicines as well as impacts of political changes that relate to it in the Continent.
References
1 Volmink J, Dare L, Clark J. A theme issue �by, for, and about� Africa. http://bmj.bmjjournals.com/cgi/content/full/330/7493/684?ehom (25 March 2005)
2 CIA. The world factbook. field listing � languages. http://www.odci.gov/cia/publications/factbook/fields/2098.html (25 March 2005)
Competing interests: None declared

Are hospital partnerships part of the answer? 27 March 2005

Caris Grimes,
PRHO
Whipps Cross University Hospital
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Re: Are hospital partnerships part of the answer?

There is a need to turn theory and talk into practical solutions when we consider the health of Africa. As a (potential) surgical trainee, I was particularly appalled at a recent visit to a hospital in Africa where the general surgeons were able to insist on bribes as well as expenses, for performing routine operations. The reason I was given for this being allowed to happen was that there were simply too few trained surgeons in the country to enable dismissal of corrupt surgeons.
Given the concern by the Royal College of Surgeons of England in this country over the decline in the amount of experience a trainee will accumulate with the new EWTD, it would seem that short stints of 6-12 months in a developing world surgical context would be beneficial to all. As long as there was proper and adequate safe supervision, there is no reason why we should not maximise on hospital-hospital links to ensure that British trainees secure a more thorough, deeper and wider ranging experience in surgery, and that surgeons in developing countries such as those in Africa also benefit by working alongside Western trainees. With such investment and real partnering between hospitals, there may be more of an incentive for African doctors to work within their own countries.
From my own observations, research skills are also often poorly/seldom taught in Africa, and again, partnerships between African and British medical and surgical trainees within partnership hospitals may benefit the hospital, and both the African/British trainees.
There is a need to move from a partnernalistic attitude to a partnership attitude and start finding practical solutions which will give real benefit to us as well as to our African colleagues. Simply speaking, if hospital trainees and workers here do not have a real incentive for some serious invovlement in such partnerships, they are in danger of becoming little more than gestures.
Competing interests: None declared

Submit papers to submit.bmj.com 29 March 2005

Jocalyn Clark,
Associate editor
BMJ London WC1H 9JR
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Re: Submit papers to submit.bmj.com

Submissions for the Africa theme issue should be made to the BMJ's online editorial office, Benchpress, at submit.bmj.com. Submmissions should follow normal BMJ guidelines; advice to contributors is available at bmj.com.
The deadline for submissions of original research to the Africa theme issue is 30 April 2005.
Best wishes
Jocalyn Clark
Competing interests: I am the editorial contact for BMJ's Africa theme issue

Something is missing 31 March 2005

Barry Pless,
Editor, Injury Prevention
Montreal Canada H3H 1p3
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Re: Something is missing

The idea of a theme issue on African health makes good sense. What is missing, however, is any reference to what may well be the major killer in African nations, as is likely the case in most of the developing world: injuries, both intentional and unintentional. True, you list 'violence against women' but, important as this may be, it no doubt pales when compared to deaths due to motor vehicle crashes, for example. True too that no doubt the list was not intended to be comprehensive. But I fear that without this reminder, injuries will once again be overlooked or for some bizarre reason, not be regarded as a health problem alongside all the problems mentioned. I urge the editors to take immediate steps to address this missing element in their otherwise laudable proposal.
Competing interests: Not competing but it might seem so from the content of this paper.

What is not mentioned, is not measured 3 April 2005

Adnan Hyder,
Assistant Professor
Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., E-8132, Baltimore, MD 21205, USA
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Re: What is not mentioned, is not measured

I strongly support your call for a special issue on Africa and the wide array of health problems. However, in the demonstration of the burden of ill health in one of the poorest regions of the world, let us not forget the health and social transitions occuring in the great continent. Africa has one of the hightest rates of injuries and violence in all of the developing world.(1) The burden of intentional and unintentional injuries is not only felt by the health sector, but by the economic and social sectors, as young people are killed, disabled, or stigmatized as a result of injuries. Collective violence, intimate partner violence, road traffic injuries, are all important causes of death in Africa; while poisoning, falls and assaults are critical causes of morbidity and disability. Most importantly, children under 15 years are frequently the victims of these public health challenges. Let us use this opportunity to bring global attention to this neglected areas of public health, and hope that it will stimulate interest for urgent action and appropriate interventions to reduce this burden on Africa.
References: 1. WHO. Global health statistics. Available at www.who.int
Competing interests: None declared

The Challenges of Health Care Delivery in Developing Countries 8 April 2005

Victor Y Ameh,
SpR in Emergency Medicine
Wythenshawe Hospital,Manchester M23 9LT,
Abdu Opaluwa, Staff Grade, General Surgery, Queen Elizabeth Hospital, Kings Lynn. PE30 4EJ
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Re: The Challenges of Health Care Delivery in Developing Countries

The challenges of healthcare delivery in a developing country such as Nigeria with its diverse ethnic and cultural groups pose is huge. Poverty, ignorance, lack of resources and health facilities and bad leadership acting in concert produce a wide spectrum of disease on one hand. On the other hand, are the sheer determinations and will of the people to survive in the face of man-made problems, strong family and community support. Furthermore, support by religious groups plays their part in giving the people hope. Overworked and overwhelmed medical personnel depend on their ingenuity and acumen to improvise in other to save lives. In the developed world, such improvisation would probably end in litigation.
Apart from infectious diseases which are largely preventable, injuries from ethnic and religious strife in some areas have direct impact on the most productive age groups which further stretches the limited resources available. Road traffic injuries are a major but neglected public health challenge and requires concerted efforts for effective and sustainable prevention(1)
There is the issue of emigration of highly trained personnel (the so- called brain drain) that further compounds the problem of healthcare delivery in Africa.
In order to tackle healthcare delivery head-on, governments must demonstrate the will to carry the people with them.
Legislation and persuasion are useful tools that can be utilised while being sensitive at every point to the culture and religious beliefs of those involved. Religious and traditional rulers in Nigeria wield a great deal of influence in their domain. It is, therefore, imperative to solicit their support in programmes aimed at improving the lot of the people. The recent recommendations of the global polio eradication initiative for example is a step in the right direction.(2) Improving the level of literacy is also vital in the fight against diseases.
The services of organisations like the British Council are immensely useful in the area of education and research. We were beneficiaries of the library outreach programme of British Council early on in our careers, which allowed us access to books and journals.
Collaboration with health institutions in other continents can facilitate training and research. The provision of grants to enable willing highly trained emigrants to go back to their �root� for brief periods may help to improve things. Such programs can be in partnership with local and regional postgraduate medical colleges..
Good governance, accountability and transparency on the part of governments and their officials will encourage not only development aid but also create conducive atmosphere for investment and job creation. This should in turn translate to availability of resources for the provision of basic amenities. A wholesome and proactive approach is required to help turn things around.
Reference:
1. WHO world report in injury prevention. Peden, M.,Scurfield R.,Sleet, D,. Mohan D., Hyder A. A.,Jarawan, E.,Mathers, C. 2004
2. Global polio Eradication Initiative. Polio News, Issue 22, Autumn 2004
Competing interests: The authors have previously worked at the Jos University Teaching Hospital,Nigeria

Injuries in African children-a quick review 14 April 2005

Ntambwe Malangu,
Senior Lecturer
University of Limpopo,
Helen A Lewis, Senior Lecturer, University of Limpopo
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Re: Injuries in African children-a quick review

Injuries in African children-a quick review
Dear Editor
We note, with concern, the comments by Adnan Hyder1, Barry Pless2, and Victor Ameh3 on the need for publications on injuries in Africa. While we concur that further research is indicated, we would like to draw the authors attention to the numerous studies on injuries published in local African journals. These publications are often overlooked as the Journals do not appear as readily in international databases as other more �visible� international Journals.4
Through an innovative effort by the International Network for the Availability of Scientific Publications (INASP), African Journals On-Line (AJOL) 5 offers a database of abstracts for about 190 African journals from 18 African countries. A quick search of AJOL using the keywords injuries and child, elicited 31 abstracts, published between 2000 and 2005, of which 22 dealt with injuries in children.
Clearly studies on injuries in Africa have been conducted and are available.6-27
The planned BMJ theme issue �by, for and about Africa�28 is most welcome as it will increase the �visibility� of research done by Africans in Africa.
References
1. Barry Pless. Something is missing. bmj.com, 30 Mar 2005
2. Adnan Hyder. What is not mentioned, is not measured. bmj.com, 2 Apr 2005
3. Victor Y Ameh, et al.The Challenges of Health Care Delivery in Developing Countries. bmj.com, 7 Apr 2005
4. Ncayiyana DJ. An uphill battle for African research and medical publishing. Mera Journal Choice March 2005;16: 4-5.
5. African Journals On-line. Available at: http://www. ajol.org
6. Nega KE and indtj�rn B. Epidemiology of burn injuries in Mekele Town, Northern Ethiopia: A community based study. Ethiopian Journal of Health DevelopmentVolume 16, No. 1, 2002
7. Shen C, Boto Sanno-Duanda, and Stephen W Bickler. Pediatric trauma at a government referral hospital in the Gambia. West African Journal of MedicineVolume 22, No. 4, 2003
8. Obajimi MO, Jumah K, Brakohuapa W, Iddrisu W. Computed tomography features of head injury in Ghanaian children. Nigerian Journal of Surgical Research. Volume 4, No. 3, 2002
9. Abdul IF. Review: Childhood and Adolescent Sexual Abuse: Incidence, Complications and Management. Sahel Medical JournalVolume 6, No. 3, 2003
10. Adigun IA, Kuranga SA, Abdulrahman LO. Grinding machine: Friend or Foe. West African Journal of MedicineVolume 21, No. 4, 2002
11. Ameh AE and Nmadu PT. Gastrointestinal injuries from blunt abdominal trauma in children East African Medical JournalVolume 81, No. 4, 2004
12. Archibong AE, Ikpi E, Ikpeme IA, Asuquo ME, Umoh MS, Akpan S. Motorcycle Related Abdominal Trauma in Children in Calabar � Nigeria. Mary Slessor Journal of MedicineVolume 3, No. 2, 2003
13. Babatunde A. Solagberu. Trauma deaths in children: a preliminary report. Nigerian Journal of Surgical Research.Volume 4, No. 3, 2002
14. Chirdan LB and Uba AF. The Management of Anorectal Injuries in a Nigerian Paediatric Tertiary Centre. African Journal of Paediatric Surgery Volume 1, No. 1, 2004
15. Fatima Kyari, Mahmoud B. Alhassan, Adenike Abiose. Pattern and Outcome of Paediatric Ocular Trauma � A 3 - Year Review at National Eye Centre, Kaduna. Nigerian Journal of OphthalmologyVolume 8, No. 1, 2000
16. Mungadi I and Abubakar U. Pattern of Paediatric Trauma in North Western Nigeria. Sahel Medical JournalVolume 7, No. 1, 2004
17. Onyekwe LO. Spectrum of Eye Injuries in Children in Guinness Eye Hospital, Onitsha. Nigerian Journal of Surgical Research.Volume 3, No. 3, 2001
18. Oyedeji GA and Oyedeji AO. Causes, Patterns and Outcome of Severe Injuries in Children � A Hospital based Study. Nigerian Journal of Paediatrics Volume 30, No. 3, 2003
19. Seleye-Fubara SD and Ekere AU. Domestic accidental deaths in the Niger Delta region, Nigeria. East African Medical Journal Volume 80, No. 12, 2003
20. Thanni LO and Folami AO. Paediatric Orthopaedic Disease Pattern In Sagamu, Nigeria. Nigerian Medical PractitionerVolume 44, No. 3, 2003
21. Ashley van Niekerk. The epidemiology of Childhood Burn Injuries: A Review of the Evidence. African Safety Promotion: A Journal of Injury and Violence PreventionVolume 2, No. 1, 2004
22. Lalloo R and Van As. Profile of children with head injuries treated at the trauma unit of Red Cross War Memorial Children's Hospital, 1991 � 2001. South African Medical JournalVolume 94, No. 7, 2004
23. Peltzer K and Mashego T. Perceptions of road traffic injury causes and interventions in the Limpopo Province, South Africa: implications for prevention. Acta CriminologicaVolume 16, No. 2, 2003
24. Sudeshni Naidoo. The Importance of Oral and Facial Injuries in Child Abuse. African Safety Promotion: A Journal of Injury and Violence Prevention Volume 2, No. 1, 2004
25. Mbembati N and Leshabari M. Childhood Burn Injuries in Children in Dar es Salaam: Patterns and Perceptions of Prevention. African Safety Promotion: A Journal of Injury and Violence PreventionVolume 1, No. 1, 2002
26. Museru LM, MT Leshabari M, Mbembati N. Patterns of Road Traffic Injuries and Associated Factors among School-aged Children in Dar es Salaam, Tanzania. African Safety Promotion: A Journal of Injury and Violence Prevention Volume 1, No. 1, 2002
27. Mutto M, Olive C Kobusingye, Ronald R Lett. The effect of an overpass on pedestrian injuries on a major highway in Kampala � Uganda. African Health SciencesVolume 2, No. 3, 2002
28. Volmink J, Dare L, Clark J. A theme issue �by, for, and about� Africa. BMJ 26 March 2005;330:685-6.
Competing interests: None declared

Controversies surrounding circumcision: Botswana 2 May 2005

Dr. Rajesh Chauhan. MBBS, DFM, FCGP, ADHA, FISCD,
Consultant, Family Medicine & Communicable Diseases
309/9 A.V. Colony, Sikandra, Agra -282007
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Re: Controversies surrounding circumcision: Botswana

Dear Editors,
Many individuals continue to die due to HIV and AIDS in Africa. Kebaabetswe�s proposal[1] on male circumcision as an acceptable strategy for HIV prevention in Botswana has generated a lot many controversies[2- 5]. Already the very subject of circumcision is marred by controversies since ages[6]. A gloomy scenario has been predicted for Botswana by demographers; in that two-thirds of the 15-year-olds will die of AIDS before the age of fifty[7]. The prevalence rate has reached 25%, or one out of every four adults in the country is infected[8]. It has the highest rate of HIV infection in the world, estimated at 36% among the population aged 15-49 years[9-12]. .
While on an overseas appointment to Botswana fourteen years ago, I reminisce having come across a few patients of the �Bakwena� and �Xhosa� tribes who were practicing male circumcision in Botswana, which was done prior to their adolescence. This centuries old tradition was still being followed by small sections of these two smaller tribes. Despite other similarities like the right mix of opportunities, background, economic strata, peer pressures, etc, these two tribes had markedly less STD related illnesses including HIV infection. Based on these observations I wanted to conduct a study on the role of circumcision in preventing the HIV infection, but the idea was not given due thought.
The HIV pandemic is still raging unabated, with no definite cure or a potent vaccine in near sight. Unfortunately by 2010, life expectancy at birth in Botswana is estimated to be as low as 33 years {13]. At this juncture, rather than getting mired down by different view points, the choice should rather be clear when looking for survival. Medical, psychological, social, sexual effects, legalities, ethics, and human rights etc can be considered later subsequent to survival strategy having been worked out. Circumcision is not a guarantee for preventing males from getting infected with HIV. Total protection cannot be assured. However, since circumcision confers a little more protection if practiced prior to reaching adolescence, it should be strongly recommended [1,14,15] in conjunction with other established means of HIV protection. However in order to be successful it needs to be done prior to reaching adolescence. Both pre and post-exposure prophylaxis can also be given a try as is recommended for post-exposure HIV prophylaxis following needle stick injuries & sexual assault[16,17].
Iatrogenic reasons have been put forth for the spread of HIV. Botswana has a very well developed medical infrastructure[18] and the circumcision can be a very safe and sterile procedure. Kebaabetswe�s team has already determined that �Batswana� are prepared to adopt the practice of circumcision1; it is high time to put ideas into practice for the male child.
REFERENCES
1. Kebaabetswe P, Lockman S, Mogwe S, Mandevu R, Thior I, Essex M, Shapiro R L. Male circumcision: an acceptable strategy for HIV prevention in Botswana. Sex Transm Infect 2003; 79: 214-219.
2. Boyle G J. Issues associated with the introduction of circumcision into a non-circumcising society. Sex Transm Infect 2003; 79: 427-428.
3. Introducing circumcision into a society will not prevent HIV infection J. Med. Ethics 2004; 30(5): 498 - 498. 4. Brody S, Gisselquist D, Potterat JJ, et al. Evidence of iatrogenic HIV transmission in children in South Africa. Br J Obstet Gynaecol 2003; 110:450�452. 5. G Hill and G C Denniston. HIV and circumcision: new factors to consider. Sex Transm Infect 2003; 79: 495-496. 6. Bailis SA.Circumcision--the debate goes on. Pediatrics. 2000; 105(3 Pt 1):682 7. Gottlieb S. UN says up to half the teenagers in Africa will die of AIDS. BMJ. 2000; 8;321(7253):67.
8. Kachapila L.The HIV/AIDS epidemic in Malawi. Int Nurs Rev 1998; 45(6):179-181.
9. Weiser S, Wolfe W, Bangsberg D, Thior I, Gilbert P, Makhema J, Kebaabetswe P, Dickenson D, Mompati K, Essex M, Marlink R. Barriers to antiretroviral adherence for patients living with HIV infection and AIDS in Botswana. J Acquir Immune Defic Syndr. 2003; 34(3): 281-288.
10. Ronald Hope K Sr. Promoting behavior change in Botswana: an assessment of the Peer Education HIV/AIDS Prevention Program at the workplace. J Health Commun. 2003; 8(3): 267-281.
11. UNAIDS (2004). 2004 Report on the global AIDS epidemic. Geneva, UNAIDS. 12. UNICEF, Ministry of Local Government Botswana (2003). Situation Analysis on Orphans and Vulnerable Children. Francistown, UNICEF, Ministry of Local Government Botswana.
13. Letamo G. Prevalence of, and factors associated with, HIV/AIDS- related stigma and discriminatory attitudes in Botswana. J Health Popul Nutr 2003; 21(4): 347-357.
14. Gayle H D, Hill G L. Global Impact of Human Immunodeficiency Virus and AIDS. Clinical Microbiology Reviews 2001; 14 (2): 327-335.
15. Bonner K. Male circumcision as an HIV control strategy: not a 'natural condom'. Reprod Health Matters 2001; 9(18): 143-155.
16. Stephenson J. PEP talk: treating non-occupational HIV exposure. JAMA 2003; 289: 287-288.
17. Rogstad K E. Sex, sun, sea, and STIs: sexually transmitted infections acquired on holiday. BMJ 2004; 329: 214-217 .
18. Sibanda EN, Stanczuk G, Kasolo F. HIV/AIDS in Central Africa: pathogenesis, immunological and medical issues. Int Arch Allergy Immunol 2003; 132(3):183-195.
Dr. Rajesh Chauhan MBBS, DFM, FISCD, FCGP, ADHA, MAIMS
Ex- Senior Medical Officer, BDF, BOTSWANA
Competing interests: None declared

Africa Theme Issue: DYING OF BREAST CANCER IN AFRICA 4 May 2005

Isaac D Gukas,
Lecturer
University of East Anglia, School of Medicine, Health Policy and Practice, Norwich. NR4 7TJ
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Re: Africa Theme Issue: DYING OF BREAST CANCER IN AFRICA

I am quite excited about the coming African Theme Issue and your desire to give mention to emerging diseases [1]. Breast cancer is one of the rapidly emerging disease entities in Africa. It is under reported [2] but the incidence is rising [3]. Like most of the other emerging diseases in Africa, the burden of the disease and magnitude of suffering from it are often overshadowed by the media and political sensation associated with headline diseases like AIDS, malaria and tuberculosis. Affected women present to hospital late with advanced stages of the disease. Locoregional control of disease requires extensive and mutilating surgery. Prostheses are not usually mentioned since they are usually either not available or out of economic reach of most patients. The above scenario usually results in loss of marriage, self esteem and independence for the woman. Since most women depend on their husbands for economic support, they can no more afford adjuvant chemotherapy, radiotherapy or long term hormonal therapy.
The five year survival for breast cancer in most Africa studies is between 5-15% [4] compared to well over 60% in the developed countries [5]. Dying and dying soon is the immediate implication of a breast cancer diagnosis in Africa. The final picture is a woman dying young, and without much financial or emotional support. She can hardly afford one dose of a strong analgesic per day. She is dying in pain, shame and sorrow.
While we focus on Africa in this theme issue, let us not forget diseases like breast cancer, having the same if not more grave implications for the African woman as HIV, vesico-vaginal fistula (VVF) or tuberculosis but receiving little attention in terms of publicity, funding (both overseas and internally) and local research.
References
1. Volmink J, Dare L, and Clark J A theme issue "by, for, and about" Africa BMJ 2005; 330: 684-685
2. Okobia MN. Cancer care in Sub-Saharan Africa- urgent need for population-based cancer registries. Ethiop J Health Dev 2003;17(2):89-98.
3. Walker AR, Adam FI, Walker BF. Breast cancer in black African Women: a changing situation. J R Soc Health. 2004;124(2):81-5.
4. Ihezue CH, Ugwu BT, Nwana EJ. Breast cancer in Highlanders. Nigerian Journal of Surgical Sciences 1994; 4:1-4.
5. Quinn M, Allen E. Changes in incidence of and mortality from breast cancer in England and Wales since introduction of screening. BMJ 1995; 311:1391-1395.
Competing interests: Formerly, consultant general and breast surgeon, Plateau State Specialist Hospital,Jos, Nigeria.

Overcoming the obstacles for effective international collaborative research work in Africa: Experience with collaborative work between Nigeria and UK 5 May 2005

Isaac D. Gukas,
Lecturer
School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK. NR4 7TJ,
Barbara A. Jennings -Senior Lecturer, Ian Harvey -Professor of epidemiology, Samuel J. Leinster - Professor of medical education, School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK
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Re: Overcoming the obstacles for effective international collaborative research work in Africa: Experience with collaborative work between Nigeria and UK

Research in Africa is crucial in order to improve health care. Lack of resources and weak infrastructure, make collaboration with more developed countries essential [1]. But there are several bottle necks. We compared the pattern of occurrence of breast cancer in Nigeria and UK [2].
The ethical approval processes in most developing countries are not well structured. Existing consent forms are generic and do not cover special collaborations like genetic studies for which there may be no equivalent phrases. It is often difficult to trace patients to request specific consent for archive material. Post and telecommunication do not always work. There are deficiencies in record keeping and data retrieval. Lack of accurate, supporting data bases like cancer registries [3], population census, and demography make proper interpretation of research information difficult. Low motivation for research amongst medical practitioners in Africa means that they often don�t quite have the same enthusiasm for a project as their external counterparts.
The problems are not insurmountable. The use of multiple sources of data may bridge the gap in supporting data base [1]. Couriers can be used as means of transporting appropriately package samples as well as for communication. It may be impractical to insist on the exact ethical requirements that are easily made in the developed countries to be made by African collaborators. Often, consideration has to be made for the many peculiar situations that exist while still protecting the �best interest� of the patient [4]. The safeguard is to plan research that allows for all of these problems rather than to encounter them midway through. Health systems and countries in Africa should make efforts to overcome some of these problems in order to make international collaborative research work more effectively [5].
Competing interests: Dr Isaac D Gukas was formerly consultant general and breast surgeon at the Plateau State Specialist Hospital Jos, Nigeria.

Re: Injuries in African children: we need more publications 5 May 2005

Isaac D. Gukas,
Lecturer
School of Medicine, Health Policy and Practice. University of East Anglia, Norwich, UK. NR4 7TJ
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Re: Re: Injuries in African children: we need more publications

I am also concerned about the concerns raised by Malangu et al [1] on the articles by Adnan Hyder[2], Barry Pless[3] and Victor Ameh[4] on the above topic. I must first commend the innovative effort by the International Network for the Availability of Scientific Publications (INASP) and African Journals On-Line (AJOL. I agree that this will go along way to bridging the gap in knowledge dissemination in Africa. How ever, I still think the point being made by the Authors you mentioned are still valid. The World Health Organization (WHO) estimated that 685,000 children under the age of 15 were killed by unintentional injuries in 2001 with up to 80% of these being from developing countries. You will agree with me that for this magnitude of problem, �31 abstracts published between 2000 and 2005, of which 22 dealt with injuries in children� is a far cry. We need articles on Childhood injuries in this Africa Theme Issue of the BMJ and indeed other journals, to give this problem the �visibility� it deserves.
Reference.
1. Ntambwe Malangu, et al. bmj.com, 13 Apr 2005
2. Barry Pless. Something is missing. bmj.com, 30 Mar 2005
3. Adnan Hyder. What is not mentioned, is not measured. bmj.com, 2 Apr 2005
4. Victor Y Ameh, et al.The Challenges of Health Care Delivery in Developing Countries. bmj.com, 7 Apr 2005
5.World Health Organization. What happens when children live in unhealthy environments? http://www.who.int/mediacentre/factsheets/fs272/en/ 20/10/2004
Competing interests: Formerly consultant General and Breast Surgeon, Plateau Specialist Hospital, Jos, Nigeria.

HIV/AIDS in Africa: Is it A, B, C or D? The answer from Africa should be 'A to D' for now and hope for more effective 'A to C' 27 June 2005

Aceme Nyika,
Research Fellow
Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban 4001, South Africa.
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Re: HIV/AIDS in Africa: Is it A, B, C or D? The answer from Africa should be 'A to D' for now and hope for more effective 'A to C'

Africa, a poverty-stricken continent with limited resources to fight the HIV/AIDS epidemic, is home to 95% of the global total (39.4 million) of people living with HIV/AIDS (PLWHA) (1). The Sub-Saharan region, with only about 10% of the global population, carries 60% of all PLWHA, and out of the global 4.9 million new HIV infections in 2004, 3.1 million (63.3%) live in this region. This is in spite of all the efforts (based on the abstinence, being faithful and condom use (ABC) prevention strategy) being made to stop the spread of the disease. The inferior social status of the majority of African women in patriarchal societies compromises their ability to negotiate for safe sex.
In light of the continuing spreading of HIV infection, the effectiveness of components of the ABC prevention strategy in Africa has been questioned. Proponents of A&B cite Uganda as an example (2-4) while effectiveness of C in African settings has been reported (5). The A&B components could be argued to be the ideal but socioeconomic factors prevailing in Africa necessitate promotion of C to complement A&B. Condom use per se should therefore not be viewed as being against African cultural and/or religious teachings, but the act of engaging in sex outside marriage in the first place is probably what is wrong. Consistency, which is analogous to compliance with prescribed medication, is critical for all components of ABC to be effective, and that is what we should address. From a public health point of view, a comprehensive approach that involves all the three components of ABC, regardless of which one is the most effective singly, would save more lives in Africa.
Antiretroviral treatment reduces deaths (D) and could create an environment that is conducive to HIV preventive practices. Currently, A to D are retarding the rise of HIV prevalence in Africa, and we hope for A to C to play a much bigger role in this regard than D.
1.UNAIDS/WHO AIDS Epidemic update, 2004. 2.Shuey et al. Increased sexual abstinence among in-school adolescents as a result of school health education in Soroti district, Uganda. Health Educ Res 1999; 14(3):411-419. 3.Stoneburner RL and Low-Beer D. Population-level HIV declines and behavioural risk avoidance in Uganda. Science 2004; 304(5671):714-718. 4.Allen T and Heald S. HIV/AIDS policy in Africa: what has worked in Uganda and what has failed in Botswana? J Int Dev 2004; 16:1141-1154. 5.Laga et al. Condom promotion, sexually transmitted diseases treatment, and declining incidence of HIV-1 infection in female Zairian sex workers. Lancet 1994; 344(8917):246-248.
Competing interests: None declared

Maternal mortality in rural Burkina Faso 13 July 2005

Issiaka Sombie,
Medical Epidemiologist
Centre MURAZ, 01 BP 390 Bobo-Dioulasso 01, Burkina Faso,
Nicolas Meda, Mich�le Dramaix-Wilmet , Odette Ky-Zerbo, SimonCousens
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Re: Maternal mortality in rural Burkina Faso

Your editorial correctly identifies maternal mortality as an important health challenge in Africa1. Using a census approach with one year recall we have recently estimated the maternal mortality ratio in a population of 44,000 women of childbearing age in Hound�, a rural district in Burkina Faso, at 406 maternal deaths per 100,000 live births (95% C.I. 281, 566). This is probably an underestimate; based as it is on recall and verbal autopsy. We probably missed some deaths altogether and may have misclassified some maternal deaths as not maternal as only 15% of all deaths among women of childbearing age were classified as maternal � a low percentage compared with other reports from similar settings2.
Nevertheless this figure is 40 times higher than in Europe or north America. With a total fertility rate estimated at 6, the lifetime risk of maternal death for a woman in this population entering the reproductive period is 1 in 35. Many of these deaths could be prevented with very simple interventions; of the 34 maternal deaths identified, 10 were due to haemorrhage, 7 were due to sepsis, and 4 followed prolonged labour.
Overall 58,8% of the families commonly reported delays in making the decision to seek care, or in obtaining transport, or in receiving care. The district hospital does not have the facilities for blood transfusion while the cost to a family of a caesarian section is 100 to 200 $US3 against an average monthly household income of is 120 $US4. In our setting, poverty is a very real barrier to progress in reducing maternal mortality.
References
1. Volmink J, Dare L, Clark J. A theme issue �by, for, and about� Africa. Call for papers. BMJ 2005; 330:684-5.
2. Stanton C, Abderrahim N, Hill K. An assessment of DHS mortality indicators. Studies in Family Planning 2000; 31: 111-3.
3. Meda N, Ky-Zerbo O, Traor� A, Fao P, Nebie Y, Traor� Y Defer MC, Diallo I, Korgo P, Sombi� I, Huygens P, Van de Perre P pour le Projet SAREDO. Mise au point d�un programme d�intervention pour une maternit� � moindre risque en milieu rural au Burkina Faso (projet SAREDO) : principaux r�sultats de l�analyse initiale de la situation dans le district sanitaire de Hound�, r�gion sanitaire de Bobo-Dioulasso. Bobo- Dioulasso (Burkina Faso) : Centre MURAZ/OCCGE, f�vrier 2001: 230 p.
4. Institut National de la Statistique et de la D�mographie (Burkina Faso). Analyse des r�sultats de l�enqu�te prioritaire sur les conditions de vie des m�nages en 1998. Ouagadougou, INSD. 280p.
Competing interests: None declared

Re: Call to governments to boost innovation for neglected diseases 4 August 2005

Bernard Pecoul,
Executive Director
Drugs for Neglected Diseases Initiative, 1 Place St Gervais, 1201 Geneva, Switzerland
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Re: Re: Call to governments to boost innovation for neglected diseases

The eight richest nations of the world have committed to providing �as close as possible� universal access to HIV/AIDS treatment and to tackle malaria and TB and other neglected diseases. The reference to �neglected diseases� in the G8 Communiqu� is heartening. We hope that, for once, promises will be fulfilled.
Meanwhile, every day over 35,000 people continue to die needlessly from neglected diseases. These diseases affect hundreds of millions, yet we lack safe, affordable, effective, field-adapted vaccines, diagnostics, and drugs to tackle them. Of 1,393 new medicines approved between 1975 and 1999, only 1% was developed for tropical diseases and tuberculosis.
Although basic science about infectious diseases exists and biomedicine is developing extremely fast, essential products for the poor are not being developed. The new drugs developed have been primarily for diseases of the rich world. In 1990, the Global Forum for Health Research estimated that a mere 10% of global investment in health R&D ($30 billion in 1986) was being applied to 90% of the world�s health problems. Although the world now spends three times as more on health research ($106 billion in 2001) this 10/90 gap is increasing.
In the last few years, this health challenge has spurred global awareness. Not-for-profit organisations such as the Drugs for Neglected Diseases initiative (DNDi), Medicines for Malaria Venture and TB Alliance have been established to accelerate innovation for neglected diseases. The majority of these are funded by philanthropic organisations and individual donors but relative to the immensity of the problem, this response is woefully insufficient. How long can patients rely on generous philanthropy while wealthy and disease-endemic governments remain only marginally involved?
Responding to the needs of the most disadvantaged populations is, at the end of day, a public responsibility. Private, for-profit and non- profit entities have a lot to contribute but cannot be accountable for the lack of adequate response.
DNDi and its Founding Partners in association with Oxfam, M�decins Sans Fronti�res, and the BIOS Initiative are leading an appeal calling governments to boost innovation for neglected diseases. The R&D Appeal urges governments to take a leadership role in addressing this health challenge by providing not just promises but significant and sustained support to bring essential new drugs, vaccines and diagnostics to people suffering and dying from neglected diseases. Governments can do this by setting up a health-needs driven R&D agenda, defining an ambitious action plan with appropriate resources, and constructing an enabling framework for the different partners similar to the successful plans that have been put in place for cancer and HIV/AIDS in rich countries.
The aim of the R&D Appeal is to collect a considerable number of signatures to present to member states at the World Health Assembly in May 2006. As physicians concerned about the well-being of patients in the poorer regions of the world, please lend your support to the Appeal by signing up at www.researchappeal.org
Your signature counts.
Sincerely,
Bernard Pecoul, Executive Director, DNDi
Competing interests: None declared

Gaining Public Support to Reduce the 10/90 Gap: A Canadian Example 9 August 2005

Bernadette Stringer,
Epidemiologist
McMaster University,
Ted Haines and Carroll Iwasiw
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Re: Gaining Public Support to Reduce the 10/90 Gap: A Canadian Example

As Canadian researchers partnered with Nigerian colleagues, supported by the Canadian Institutes of Health Research Global Health Program, we concur with Dr. Bhutta's 2003 BMJ editorial that more effective funding of health research in the developing world is needed. But how do those who agree convince funding institutions of the importance of reversing the 10/90 gap? We argue that the essential requirements for change are more cultural and political than scientific or medical.
One might expect a Canadian consensus that the world is one community, because so many of us come from other continents and most Canadians cite multiculturalism as a defining �national� characteristic. Yet, we rank relatively low in foreign aid at 0.24% of GDP and health research spending is overwhelmingly on development of drugs to produce corporate profits. While Canadians consider themselves world citizens, our economic system much more strongly influences the definition of research priorities than desire to reduce the global disease burden.
Still, the Canadian experience offers insights about how to create contexts where the profit motivation is not paramount. Although our neighbour to the south is the only rich nation not to offer comprehensive universal medical coverage and we receive aggressive propaganda against �socialized� medicine, Canada�s Medicare system is so popular that governments must defend it or risk political oblivion.
The lesson that should be applied to reducing the 10/90 gap is demonstrating that the research makes a difference in the lives of ordinary people, who have friends and family here in Canada. We must convince our citizens, our taxpayers, that it is in �their� self-interest to do this kind of research. Our Nigerian-Canadian partnership on preventing occupational transmission of bloodborne pathogens can have such an impact. The Canadian defence of universal healthcare proves this sort of self-interest can overcome the profit motive. References
1. Bhutta Z. Practicing just medicine in an unjust world. Initiatives to improve academic medicine in developing countries must come from within. BMJ 2003; 327: 1000-1001.
2. Statistics Canada. Canada�s ethnocultural portrait: The changing mosaic. Available at: http://www12.statcan.ca/english/census01/products/analytic/ companion/etoimm/canada.cfm#proportion_foreign_born_highest. Accessed 30/04/05.
Competing interests: None declared

Palliative Care in the era of Antiretroviral treatment 18 August 2005

Richard Harding,
Lecturer
Department of Palliative Care & Policy, King's College London, SE5 9RJ, UK,
Catherine Senyimba, Edmund Mwebesa, Siobhan Kennelly, Karen Frame
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Re: Palliative Care in the era of Antiretroviral treatment

The estimation of 80 million AIDS-related deaths in Africa by 2025 is very concerning (1). In the era of expanding access to antiretroviral therapy (ART) in Sub-Saharan Africa, the WHO advocates palliative care integration because pain, other distressing symptoms, and complex psychosocial challenges persist throughout the HIV trajectory (2). The specialism improves HIV patient outcomes (3), and in Africa may compliment ART provision through aiding adherence through side effect management, providing patient and family centred holistic care, and end of life care where necessary (4). However, it brings the challenge of re-integrating what have become distinct disciplines: HIV medicine and palliative care (5). Hospice Africa Uganda was founded to provide affordable pain and symptom control, including oral morphine, and to develop a model of palliative care appropriate to Africa. It provides advocacy and training across Africa, education, and specialist palliative care in rural and urban settings alongside community volunteers and traditional healers. Through links between ART clinics and Hospice, patients are provided with the benefits of ART in controlling disease progression while simultaneously accessing symptom and side effect management, psychosocial support, and end-of-life care as required.
To evaluate the success of integrated care, we aimed to measure both referrals and clinical management. We reviewed patient files for new referrals from March-August 2004. Of 311 referrals to Hospice, 106 had HIV disease (34.1%). 39 were accessing ART at referral (36.8%), a further 12 (11.3%) had accessed ART previously but had defaulted. Among those 39 accessing ART, primary referral reasons were severe pain (n=32, 82.1%), skin rash (n=4, 10.3%), diarrhoea (n=2, 5.1%), and nausea and vomiting (n=1, 2.6%). Morphine had been accessed by 10 patients prior to referral, and was initiated by Hospice for a further 72 patients at first visit (67.9%). Chemoprophylaxis was initiated for 73 patients (68.9%), and 46 required treatment for opportunistic infections. Of 67 patients not on ART at referral, 45 (67%) were referred to an ART clinic for treatment.
Although HAU does not provide ART, our data demonstrate how a palliative care provider can network with HIV/AIDS clinicians for integrated care. It is unnecessary for patients or clinicians to choose between palliative care and ART. This novel African service offers insight into achieving optimal ART/HIV care in other resource-poor countries, and perhaps also offers lessons to resource-rich settings where unresolved symptoms and poor adherence persist.
(1) Volmink J, Dare L, Clark J.A theme issue "by, for, and about" Africa. Br Med J 2005; 330:684-685.
(2) WHO. HIV palliative care. WHO:Geneva. http://www.who.int/hiv/topics/palliative/care/en/ (accesssed 29th April 2005)
(3) Harding R, Easterbrook P, Karus D, Raveis VH, Higginson IJ, Marconi K. Does palliative care improve outcomes for people with HIV/AIDS? A systematic review of the evidence. Sex Trans Infect 2005;81:5-14.
(4) Harding R, Higginson IJ. Palliative Care in Sub-Saharan Africa: an appraisal of reported activities, evidence and opportunities. Lancet 2005;365:1971-1977.
(5) Harding R, Karus D, Raveis VH, Higginson IJ, Easterbrook P, Higginson IJ. Barriers and inequalities in palliative HIV/AIDS care: a review of the evidence and responses. Palliat Med 2005;19, 251-258.
Competing interests: None declared

Advantages of Reversing African Brain Drain 18 August 2005

Joseph N Ana,
mentor, BMJ West Africa
BMJ West Africa,
20 Eta Agbor Road, Calabar, Nigeria
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Re: Advantages of Reversing African Brain Drain

ADVANTAGES OF REVERSING AFRICAN BRAIN DRAIN ( BRAIN GAIN and BRAIN CIRCULATION)
Recently the President of Nigeria hosted a meeting of the Nigerians in Diaspora Organization of Europe and USA ( NIDOE) in Abuja, the capital city of Nigeria to discuss how the thousands of Nigerian professionals in various fields can assist in the escalating restructuring and rebirth of the social, economic and cultural sectors of the country. In the last decade, the damaging effects of the exodus of Africans from their continent to Europe, America and other parts of the world in search of a better life has been widely documented in the media, books and magazines. No profession is spared but some have more dramatic effects than others. The exodus of doctors, nurses, lecturers, teachers, engineers for instance has led to the near total breakdown of these sectors. Africa today has the highest disease burden but the lowest doctor : patient or nurse ratios. Class sizes are unimaginable when compared to the West where most African teachers emigrate to for greener pastures. As a result products of once world class educational institutions are now dodgy at best and down right semi illiterates in some cases. Town planning and maintenance are pipe dreams leading to increasing environmental degradation, squalor, disease and crime . But as the Nigerian Medical Forum UK, a U.K. based registered charity of Nigerian doctors and health professionals, discussed at the Vision 2010 health committee of the federal government of Nigeria in 1997, emigration of Nigerians to the richer more technologically advanced world is not all bad, especially when such Africans eventually make a re-entry to their African homes. To begin with, these Africans in diaspora remit very large sums of money and goods to their kit and kin back home in Africa , indirectly improving the foreign exchange position of African countries. Only last week the Nigeria National Health Insurance Scheme launched the Diaspora programme to enable Nigerians abroad pay for the health needs of their family and friends back home. More importantly when Africans abroad make the sacrifice to leave their lucrative business to return home, and they are given the opportunity, they usually serve their home country immeasurably, imparting skills and knowledge and also helping to improve the quality of life of the local population.
At a time when Africa, because of democratization, is beginning to unshackle itself from the ravages of decades of dictatorship governments, efforts must be made to tap the massive potentials in Africans abroad either by way of a full return to home or structured, periodic visits ( Brain Circulation). Brain Gain will not occur if there was no brain drain, so after all, the movement of Africans in the 1980s and 1990s to Europe and America is not all bad. With democratization and good governance in Africa, Africans will revert to what happened before the 1980s, when they emigrated only for knowledge and skills, and promptly returned to their home country better equipped and knowledgeable to serve mother Africa.
Dr Joseph Ana, FRCS, DUrology (London) Commissioner for Health Ministry of Health Cross River State of Nigeria ( specialised and practiced medicine / surgery in the UK for 22 years before returning to Nigeria in 2004 to serve)
Competing interests: None declared

Cancer hidden in the shadow of AIDS: It's time to wake up to the toll of cancer in Africa 20 August 2005

Scott A Murray,
Reader, Primary Palliative Care Research Group
University of Edinburgh EH8 9DX,
Elizabeth Grant, Faith Mwangi-Powell
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Re: Cancer hidden in the shadow of AIDS: It's time to wake up to the toll of cancer in Africa

The focus of health services in Africa on maternal and child health, TB, leprosy, and malaria, have been overshadowed more recently by the HIV/AIDS pandemic. Cancer remains relatively neglected in Africa although increasingly prevalent: 70% of people with cancer live in the economically developing world, where by 2020 it is predicted that the annual death toll will reach 20 million.1
In sub-Saharan Africa, measures to prevent cancer, emphasised in the developed world � such as smoking cessation, and screening � are not nationally adopted. One third of African cancers are preventable; but the influence of tobacco companies with mass media advertising and high crop payments are real. Traditional cancers such as gastric and hepatocellular carcinoma, and newer cancers, such as lung, breast and AIDS related Kaposi�s sarcoma are increasing in incidence. 2,3
Patients� expectations for oncological treatment are low in Africa. Lack of money, or a concern not to place their family in debt, frequently prevents patients seeking medical help.4 Lack of awareness of predisposing factors, warning symptoms or signs of cancer, or treatment options mean that patients present late. Cost and difficulty of travel over rough terrain also discourages service utilisation. Indeed after realising their diagnosis, patients may tend to look for peace of mind and spiritual comfort rather than for a physical cure.
In Africa, disease-modifying cancer treatment and basic symptom control are both largely absent. Even when analgesia is available, patients with cancer may still experience severe and inadequately managed pain, as health professionals under-prescribe strong analgesics, fearing drug-dependency.5 For humane cancer care in Africa, an analgesic �ladder� and other symptom control medications must be available and affordable.
Individual sub-Saharan countries cannot address the challenges of cancer in isolation. A new cooperative approach and research base is being advocated for the prevention, treatment and palliation of cancer to bridge the gap between developed and developing nations. 5 The world�s high income countries should work in partnership with poor countries to help scale up their health systems to provide access for all to a limited number of essential health interventions. Heath has recently called for a shift of health service resources from the worried well in developed countries to the sick in poorer nations, asking �who needs health care- the well or the sick?� 6 Are programmes to prevent, diagnose and treat cancers essential or a luxury Africa still cannot afford?
1. Murray JL, Lopez AD. The Global Burden of Disease. Harvard School of Public Health, Boston, 1996.
2. Morris K. Cancer? In Africa? Lancet Oncology 2004;4, 1:5-6.
3. Walker AR, Adam FI, Walker BF. Breast cancer in black African Women: a changing situation. J R Soc Health. 2004;124(2):81-5.
4 Murray SA, Grant E, Grant A, Kendall M. Dying from cancer in developed and developing countries: lessons from two qualitative interview studies of patients and their carers. BMJ 2003;326:368-71.
5. World Health Organization. National Cancer Control Programs. World Health Organisation, Geneva 2005.
6. Heath I. Who needs health care - the well or the sick? BMJ 2005;330:954.
7. Olweny C. Ethics of palliative care medicine: Palliative care for the rich nations only! Journal of Palliative Care 1994;10:3:17-22.
Competing interests: None declared

Preventing mother-to-child transmission of HIV: have we prematurely discarded vaginal disinfection? 25 August 2005

Charles Shey Wiysonge,
Research Fellow
University of Cape Town, The Cardiac Clinic, E25 Groote Schuur Hospital, Observatory 7925, RSA,
Muki Shehu Shey
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Re: Preventing mother-to-child transmission of HIV: have we prematurely discarded vaginal disinfection?

When one thinks of Africa�s health challenges today (1), one�s mind unavoidably turns to the ravages of the HIV pandemic; and then perhaps to operational issues of antiretroviral drug availability. The most tragic consequence of the pandemic is transmission of HIV infection from an infected mother to her child. Interventions currently advocated for reducing the risk of mother-to-child transmission of the infection include a short course of antiretroviral drugs and alternatives to breastfeeding (2). Given that vaginal exposure is an important route of HIV infection (3), interventions targeting the birth canal (such as avoidance of vaginal delivery or vaginal disinfection) might play a key role in reducing the paediatric HIV burden in resource-constrained settings such as Africa.
Caesarean section delivery significantly reduces mother-to-child transmission of HIV by about 50%, but technical and logistical difficulties limit its widespread use in sub-Saharan Africa (4). But does vaginal disinfection reduce the risk of mother to child transmission of HIV infection? A systematic review of randomised controlled trials (5) demonstrates that there is insufficient evidence to either support or refute the use of this intervention. Available data (6,7) show a 6 percent reduction in the risk of mother-to-child transmission, with wide confidence intervals (- 29 percent to +25 percent). Given its simplicity and low cost, there is need for an adequately powered randomised controlled trial to assess the effect of vaginal disinfection on the risk of mother-to-child transmission of HIV or, more appropriately, the additive effect of vaginal disinfection in antiretroviral treated women.
1. Volmink J, Dare L, Clark J. A theme issue "by, for, and about" Africa. BMJ 2005;330:684-685.
2. Volmink J. HIV: mother to child transmission. Clin Evid 2004;11:902-12.
3. Newell ML. Mechanisms and timing of mother-to-child transmission of HIV -1. AIDS 1998;2(8):831-7.
4. Read J, Newell ML. The efficacy and safety of cesarean delivery for prevention of mother-to-child transmission of HIV-1: a systematic review (Cochrane Collaboration). Abstract TuPp0406. 3rd IAS Conference on HIV Pathogenesis and Treatment, 24-27 July 2005, Rio de Janiero, Brazil.
5. Wiysonge CS, Brocklehurst P, Sterne JAC. Vaginal disinfection during labour for reducing the risk of mother-to-child transmission of HIV infection The Cochrane Database of Systematic Reviews 2002, Issue 2: CD003651.
6. Gaillard P, Mwanyumba F, Verhofstede C, Claeys P, Chohan V, et al. Vaginal lavage with chlorhexidine during labour to reduce mother-to-child HIV transmission: clinical trial in Mombasa, Kenya. AIDS 2001;15(3):389- 96.
7. Mandelbrot L, Msellati P, Meda N, Leroy V, Likikouet R, et al. 15 Month follow up of African children following vaginal cleansing with benzalkonium chloride of their HIV infected mothers during late pregnancy and delivery. Sex Transm Infect 2002;78(4):267-70.
Competing interests: None declared

�Flashblood� and HIV risk among IDUs in Dar es Salaam, Tanzania 25 August 2005

Sheryl A. McCurdy,
Assistant Professor
University of Texas Houston Health Science Center, SPH, 7000 Fannin, #2520, Houston, TX 77030,
Mark. L. Williams, Michael W. Ross, Gad P. Kilonzo, and M.T. Leshabari
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Re: �Flashblood� and HIV risk among IDUs in Dar es Salaam, Tanzania

During 2005, female sex workers who are heroin injectors in Dar es Salaam, Tanzania created a new needle sharing practice they call 'flashblood'. Flashblood is the English term Swahili speakers use to describe drawing blood back in a syringe until the barrel is full, and then passing the syringe to a female companion who injects the blood. By injecting the syringe, about 4 cc�s of blood, women believe that they can avert symptoms associated with heroin withdrawal because the first injector�s blood is thought to have �some heroin in it.� Female sex workers began the flashblood practice amongst themselves in the last couple of months in an altruistic attempt to help their impoverished and more desperate associates. Male injectors interviewed are still unaware of this practice. These data are based on ongoing in-depth interviews with 63 heroin injectors.
The rationale for flashblood may be the price and quality of heroin in Dar es Salaam. During 2003, one kete of high quality, mostly pure white heroin cost US$0.50. One kete was all many injectors needed to get high. Now the price of heroin has increased to US$1 per kete, and the heroin is reportedly adulterated. By the summer of 2005, most injectors claimed they need two kete to get high.
Most female heroin users in Dar es Salaam trade sex for money to support their habits. Women most affected by the increase in cost and decline in quality of heroin are those who are in poor health as the result of chronic heroin abuse. Because of their appearance and obvious poor health, these women are unable to attract enough clients to support their habits. Other female injectors still able to attract customers for sex have begun accommodating women in more desperate circumstances by providing them with flashblood.
Female sex workers in Dar es Salaam prefer to use condoms with their clients, but when desperate for money or drugs will agree to forgo the condom at the clients� request. Many Tanzanian men prefer not to use condoms and routinely ask female sex workers not to use them. Female heroin injectors who are desperate, like the women who accept �flashblood�, are the most likely to agree to forgo condoms. In their sexual relationships with intimate partners most women and men do not use condoms.
Research on the relationship between drug injection and HIV transmission has long focused on the serial use of syringes/needles, practices such as "backloading�, and reuse of paraphernalia used to prepared drugs prior to injecting (Johnson and Williams 1992, Needle et al., 1999; Zhou et al., 1994). The practice of flashblood is a new phenomenon that is, in a sense, a dangerous exaggeration of the practice of needle sharing which magnifies HIV transmission risk beyond backloading. Rather than injecting a very small quantity of blood residue, women who practice flashblood inject several cc�s of blood. If the first injector is HIV or HCV infected, the amount of virus directly transmitted into the bloodstream by the second injector could be quite large.
The only apparent reason for the emergence of flashblood in Dar es Salaam is the idea that blood drawn immediately back into the syringe after injecting contains enough heroin to help a second injector escape the pains of withdrawal. To our knowledge this is a myth, as there is not enough heroin in a syringe of flashblood to do anything other than provide a placebo effect. Myths and rumours, however, are powerful motivators and explanatory devices. During the 1920s in East, Central, and Southern Africa, mumiani rumours circulated about European vampires who used human blood for medical purposes. Tranfusion technology and the concept of blood donation emerged in Africa at the same time that an intensification of colonial efforts at domination were exerted post World War I. At that time, some Africans believed that Europeans drained the blood of Africans to provide it to anaemic Europeans (White, 2000). Some older East Africans still believe that British colonial use of mumiani explains why there was enough blood in blood banks prior to independence, but a lack of supply now (White 2000, McCurdy field notes, 1993). Perhaps traces of these rumours are the source of flashblood.
Injection drug use has now reached almost all developing nations in the world (Aceijas et al., 2004; McCoy and Rodriquez, 2005). The practice has emerged in East Africa in the last 5 to 6 years, and it is spreading rapidly throughout the region (Beckerleg, 2004, Beckerleg and Hundt 2004, McCurdy et al. 2005). If the practice of �flashblood� spreads from Dar es Salaam to other cities in East Africa, its impact on the rate of HIV and HCV transmission could be substantial. The emergence of the practice of flashblood promises only to intensify the AIDS epidemic. Injection drug use in developing countries, and local cultural variations that may exacerbate HIV transmission risk, must be recognised by national governments and international organisations. Further research is desperately needed to develop culturally appropriate HIV/HCV risk reduction interventions and drug treatments programmes.
REFERENCES
Aceijas C, Stimson GV, Hickman M, Rhodes T. (2004). United Nations Reference Group of HIV/AIDS Prevention and Care among IDU in Developing and Transitional Countries. Global view of injecting drug use and HIV infection among injecting drug users. AIDS 18: 2295�303.
Beckerleg, S. (2004). How 'Cool' is heroin injection at the Kenya coast. Drugs: Education, Prevention & Policy (11)1, 67-78.
Beckerleg, S., Hundt, G. L. (2004). The characteristics and recent growth of heroin injecting in a Kenyan coastal town. Addiction Research & Theory (12)1, 41-54.
Johnson J, Williams, M. (1992). Nuance of needle sharing among intravenous drug users in Houston. Southern Medical Journal 85(7), pp. 784 -5.
McCoy, C.B., Rodriguez, F. (2005). Global overview of injecting drug use and HIV infection. www.thelancet.com 365, 1008-1009.
McCurdy, S.A., Williams, M.L., Kilonzo, G.P., Ross, M.W., Leshabari, M.T. (2005). The emerging heroin epidemic in Dar es Salaam, Tanzania: Youth hangouts, maghetto and injecting practices. AIDS Care 17 (Supplement 1): S65-76.
Needle, R.H., Coyle, S., Cesari, H.., Trotter, R., Clatts, M., Koester, S., Price, L., McLellan, E., Finlinson, A, Bluthenthal, R.N., Pierce, T., Johnson, J., Jones, T.S., Williams, M. (1998). HIV risk behaviors associated with the injection process: multiperson use of drug injection equipment and paraphernalia in injection drug user networks. Substance Use and Misuse 33(12), 2403-23.
White, Luise. (2000). Speaking with vampires: Rumor and history in colonial Africa. Berkeley: University of California Press.
Zhuo Z, Williams, M., Bell, D. (1994). An evaluation of drug injection behaviors and HIV infection. National AIDS Research Consortium. International Journal of Addiction 29(12), 1499-518.
Competing interests: None declared

Diabetes in Africa: addressing the challenge 1 September 2005

David Beran,
Project Coordinator
International Insulin Foundation London N19 5LW, UK,
John S. Yudkin
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Re: Diabetes in Africa: addressing the challenge

Editor �The editorial by Volmink, Dare and Clark,1 announcing the BMJ�s special issue on Africa, identifies diabetes as one of the continent�s emerging challenges.
The International Insulin Foundation (IIF) has addressed the problems faced by patients in 3 countries in Africa in accessing diabetes care and insulin. This was done using a Rapid Assessment Protocol (RAPIA), which enabled data to be collected at all levels of the system from the Ministry of Health down to individual patients. The results from Mozambique and Zambia2 highlight the high cost of insulin to the health system and individual patients. While the average price per 10ml vial of U100 insulin in the public sector in Mozambique and Zambia was around US$2-3, supplies were intermittent � and insulin cost over $15.00 per vial (approximately 1 month�s need) in the private sector. There were also problems accessing syringes and diagnostic tools. Only 6% of health facilities surveyed in Mozambique had the facilities for blood glucose measurement in comparison to 25% in Zambia. These hurdles with regards to accessing supplies were combined with a paucity of trained healthcare workers. These factors lead to the life expectancy of a child with newly diagnosed Type 1 diabetes being only 0.6 years in rural Mozambique.2 Differences in life expectancy are found between urban and rural areas and also between countries and mirror the availability of supplies and quality of care.
Diabetes as a major emerging public health problem in Africa needs to be addressed. While numerically this principally relates to Type 2 diabetes, Type 1 diabetes has been used as a tracer condition for effective health care systems.3 The RAPIA has provided the Ministries of Health in Mali, Mozambique and Zambia, with baseline data on how their health system works with regards to the care of diabetes. In parallel it has helped Diabetes Associations gain better knowledge about the situation of people with diabetes in different parts of their countries, and raised the profile of diabetes with the health authorities. The RAPIA is also the first step in the necessary shift from acute to chronic care, proposed by WHO,4 as it identifies the gaps in the health system�s ability to provide care for chronic conditions and proposes concrete actions to address them.
1. Volmink J, Dare L, Clark J. A theme issue "by, for, and about" Africa. BMJ 2005;330:684-685.
2. Beran D, Yudkin J, de Courten M. Access to Care for Patients With Insulin-Requiring Diabetes in Developing Countries: Case studies of Mozambique and Zambia. Daibetes Care 2005;28(9):2136-40.
3. Kessner DM, Carolyn, E.K., Singer, J. Assessing health quality: the case for tracers. N Engl J Med 1973;288:189-94.
4. Epping-Jordan J, Pruitt S, Bengoa R, Wagner E. Improving the quality of health care for chronic conditions. Qual Saf Health Care 2004;13:299-305.
Competing interests: None declared

Implementation of a program for the prevention of mother-to-child transmission of HIV in a ugandan hospital over 5 years : challenges, improvements and lessons learned 5 September 2005

Marina Giuliano,
Researcher
Istituto Superiore di Sanit� Viale Regina Elena 299 00161 Rome Italy,
Michele Magoni, Luciana Bassani, Pius Okong, Praxedes Kituka Namaganda, and Saul Onyango
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Re: Implementation of a program for the prevention of mother-to-child transmission of HIV in a ugandan hospital over 5 years : challenges, improvements and lessons learned

Since the first demonstration of the efficacy of antiretroviral drugs in prevention of mother-to-child transmission (PMTCT) of HIV much effort has been devoted in many countries in Africa to implement sustainable regimens (1-4). In order to identify potential reasons affecting uptake we evaluated the 5-year performance of the PMTCT programme at St. Francis Hospital Nsambya in Kampala, Uganda. The programme included voluntary counselling and confidential HIV testing for pregnant women and administration of antiretroviral prophylaxis in the peripartum period (with either zidovudine or nevirapine) for those HIV-positive.
Overall 24,133 women received PMTCT counselling, 76% accepted to be tested and 2,011 were found HIV-positive; 1,341 (66.7% of the HIV-positive) were enrolled in the programme and received antiretroviral drugs.
Our evaluation shows that : a) acceptance of the test increased from 72.7% in 2000-2002 to 79.9% in 2003-2004 when a drug access program became available in the hospital. This indicates that the availability of antiretroviral treatment can influence the willing to know the serostatus; b) acceptance of the test and enrolment in the programme were lower in married or cohabitating women (78%) with respect to single women (70.5%) suggesting that the fear to be identified as HIV+ in the family is still a strong limiting factor and that male involvement could have an important role; c) women belonging to the local tribe in Kampala (Baganda) had a lower acceptance of the test (because of the probable fear of being recognized by known hospital health workers) further underlining the need to address the issue of social discrimination; d) higher education was associated with a lower HIV prevalence and with a higher enrolment in the program confirming that education can have a key role not only in protecting from HIV but also allowing those HIV-positive to benefit of existing measures, such as PMTCT, against the spread of HIV.
REFERENCES
1. Stringer EM, Sinkala M, Stringer JSA, Mzyece E, Makuka I, Goldenberg RL, et al. Prevention of mother-to-child transmission of HIV in Africa: successes and challenges in scaling-up a nevirapine-based program in Lusaka, Zambia. AIDS 2003;17:1377-82.
2. Temmerman M, Quaghebeur A, Mwanyumba F, Mandaliya K. Mother-to- child transmission in resource poor settings: how to improve coverage? AIDS 2003;17:1239-42.
3. Perez F, Orne-Gliemann J, Mukotekwa T, Miller A, Glenshaw M, Mahomva A, Dabis F. Prevention of mother to child transmission of HIV : evaluation of a pilot programme in a district hospital in rural Zimbabwe. BMJ 2004;329:1147-50
4. Painter TM, Diaby KL, Matia DM, Lin LS, Sibailly TS, Kouassi MK, Ekpini ER, Roels TH, Wiktor SZ. Women's reasons for not participating in follow up visits before starting short course antiretroviral prophylaxis for prevention of mother to child transmission of HIV: qualitative interview study. BMJ. 2004; 329:543.
Competing interests: None declared

Capacity building in collaborative research between developed and developing countries 16 September 2005

Prem K. Mony,
Asst. Professor
St. John's National Academy of Health Sciences, IPHCR, Bangalore-560034, India,
Mario Vaz, Anura Kurpad
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Re: Capacity building in collaborative research between developed and developing countries

There is serious under-representation of scientists from developing countries in various areas of health research (1, 2). Capacity building in developing countries is essential to improve health research and reduce health inequity (3, 4). We report a retrospective analysis of original articles that appeared in the British Medical Journal, The New England Journal of Medicine and the Journal of Epidemiology and Community Health between October 2003 and September 2004. We noted information on the number of contributing authors and their country affiliation by income (5). We also classified the scientific contributions of authors from midlle- and low-income countries as being �major and intellectual� (contributing to 2 out of 3: study conception/design, analysis, and intellectual contribution to manuscript drafting) or �operational� (contributing to data collection, routine supervision, etc.).
659 articles were reviewed in the three journals. The median (range) number of authors per article was 5 (1-29). Single-author publications were rare (3.2%). The number of articles which included authors from high- (HIC), middle-(MIC), and low-income countries (LIC) were 646 (97.8%), 49 (7.4%) and 11 (1.6%) respectively. Forty seven (7.1%) of the articles were products of collaborations between authors from different country groups: 38 (between HIC and MIC), 7 (between HIC and LIC) and 1 (between HIC, MIC and LIC). The nature of collaboration was such that the authors from MIC and LIC had mostly �operational� roles in research (Table 1). In two instances (0.3%), research papers had no representation from the low- income countries where the research was conducted.
Equity in health research is important to reduce health inequity. Thus, while the research agenda in developing countries may be partially driven by richer country partners who obtain financial and intellectual capital needed for research, healthy partnerships that foster local capacity need to be pursued. Partnerships that give inadequate representation to scientists from developing countries may in some cases be exploitative. Where represented, scientists from developing countries fulfill largely �operational� roles in research. There is a need to transform such research collaborations into genuine partnerships with the aims of mutual learning and local capacity building. Collaborative research programmes that �outsource� the operational aspects of research while retaining intellectual capital in the developed world cannot fulfill the needs of developing countries or of global health. In addition, editorial boards of journals need to be aware of the potentially exploitative nature of reporting of collaborative research between developed and developing countries. There is no better time than now for us to translate into practice the rhetoric of strengthening research capacity in developing countries.
Table 1. Extent and nature of research collaborations between countries classified by income in the three study journals
Characteristic No. (%) Total no. of articles (N) 659 (100.0%) No. of articles based in a middle/low-income 2 (0.3%) country but with no local representation* No. of research collaborations involving authors from*: Middle-income countries 38 (5.8%) Low-income countries 9 (1.3%) Total (n) 47 (7.1%) Role of the authors from middle/low-income countries in research collaborations**: Predominantly intellectual 12 (25%) Predominantly operational 35 (75%) * percentages are out of �N� ** percentages are out of �n�

Competing interests: None declared

Africas problems easier to solve 17 September 2005

John P Heptonstall,
Director of the Morley Acupuncture Clinic
Leeds LS27 8EG
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Re: Africas problems easier to solve

Africa is not a "basket case"; it is those who force Africans to continue to live in poverty and sickness who are basket cases.
Africas problems are much easier to solve than most of the rhetoric implies; remove the reins from the basket cases, who continue to force Africans into poverty and sickness, and place them in the hands of decent honourable Africans themselves.
Billions of dollars can buy sanitation, employment, engineering, clean air, clean water, food and essential medicines aplenty - so why are we not hearing of these simple priorities?
If this is to be Africas year we should ensure that our hard earned monies fall not into the hands of corrupt commercial dealers who generate corrupt African commercial and political pawns, but are targetted at honourable decent Africans to rebuild and re-sanitise their environments, re-nourish their people, and develop their industries to realise the wealth beneath their feet that has been denied them for generations.
Regards
John H.
Competing interests: None declared