Thursday, 24 July 2008

Meetings of Nigerians at the last 4 International AIDS conferences

by chikwe ihekweazu and ike anya

At all of the previous four international conferences on AIDS that we have attended, there are always meetings called for all Nigerians attending or those working on HIV/AIDS in Nigeria. The meeting at the Durban conference in 2000 was chaired by Professor Ibironke Akinsete the then Chairperson of NACA, while the meetings at the last three conferences have been chaired by Professor Babatunde Osetimehin, the incumbent Chair of NACA which has since changed from a committee to a full fledged parastatal under “The Presidency”. We have attended all 4. Below are our thoughts...moving forward...

At the meeting in Durban in 2000 at the Chamber of Commerce Building, Stanger Street, Durban there were 104 Nigerians gathered with one common interest; HIV/AIDS in Nigeria. This meeting was the initiative of Mr Omololu Falobi (RIP) (add link) and was heralded to signal a new spirit of dialogue. Just a year into our new democracy, a HIV prevalence that had just crossed the 5% mark, a new “National Action Committee on AIDS” etc, Nigerians were indeed enthusiastic about defining the way forward. The room was filled to capacity as people kept pouring in. Wearing identification tags from a wide variety of different countries it became obvious that Nigerians were indeed involved in HIV/AIDS research and activism all over the world. A wide variety of issues were discussed…a plan to place the first 10,000 patients on ARVs, a new strategic plan, negligence of NGOs, poor research capacity and the pervasive “Abalaka issue” (add link), who was absent. In attendance at that meeting included Prof. Maurice Iwu, a active researcher on alternative medicines for diseases before his foray into election management. : It was agreed to that the problem of inadequate research into the AIDS situation in Nigeria was definitely not due to lack of human resources as evidenced by the participants in the forum, however there was a large ignorance of each other and their activities. The decision was taken to compile a resource bank which would hopefully be a starting point for a change of attitude. Names, addresses and affiliations of those in attendance were collected by NACA. We left…full of hope. (minutes available on request)

In Spain in 2002, the next meeting held at the Fira Palace Hotel, in Barcelona. Over 130 Nigerians attended the meeting and was chaired by Professor Babatunde Osotimehin, the director-general of the newly-created National Agency for Prevention and Care of HIV/AIDS (NAPCA) (later dissolved by the National Assembly). As usual, in typical Nigerian fashion…we took the first hour to introduce ourselves with our inevitably long profiles . This meeting was interesting in the large attendance of research partners interested in supporting Nigeria; the National Institutes of Health, Fogarty International Center, the Institute of Human, Virology of University of Maryland, as well as the Harvard School of Public Health. Dr Phyllis Kanki of the Harvard School of Public Health (HSPH) gave delegates an insight into the activities of the AIDS Prevention Initiative in Nigeria (APIN) one of the largest early HIV?AIDS response programmes in Nigeria supported by the HSPH and the Bill and Melinda Gates Foundation. Professor Osotimehin then informed us that there was now “Political will” at the highest level in Nigeria to move the agenda forward in Nigeria, however the consensus in the house was that this had not trickled down to other levels of leadership in Nigeria. He was announced that a pilot programme for ARVs had been successfully initiated by the Federal Government and that arrangements had reached advanced stages for the commencement of a Prevention of Mother to Child Transmission (pMTCT) programme in Nigeria. The last contribution of the day was made by a person living with HIV who called on all delegates to show sincerity, honesty and commitment in the efforts to stem the epidemic in Nigeria. He stressed the need to match words with action in line with the theme of the AIDS conference. Again we left…full of hope. (minutes available on request)

In Bangkok in 2004, there was another meeting of Nigerian delegates featuring a key challenge from an HIV/AIDS activist, Rolake Odetoyinbo who challenged the leadership on their perceived failures in adequately making use of the resources available through the Global Fund for AIDS TB and Malaria. Her contribution illustrated the usefulness of the links that had been forged between Nigerian activists and the wider global community. There were also sadly stories of infighting among key leaders and researchers which were impeding progress, and concerns were raised about the adequacy of the Nigeria exhibition stand in the exhibition hall.

At the last conference in Toronto in 2006, Nigerians attended again; No surprise there! Yet, despite the obvious huge numbers of Nigerians in attendance and the ubiquitous presence of Professor Babatunde Osotimehin with his large entourage of staff moving around the conference venue, there was little information about a meeting this time. We wondered if we had lost steam. However, on the third day of the conference, word quickly spread that there was indeed to be a meeting of all Nigerians present at the conference, convened the NACA chief executive. Some delegates grumbled at the meeting being convened by NACA even when the body did not know how some Nigerians had managed to make their way to the conference, the turn-out at the meeting was large, overwhelming the tiny meeting room that had been arranged for the purpose. Prospects for the success of the meeting were not improved by the loud drumming coming from the nearby Global Village, which nearly drowned out the Chairman’s introductory remarks.

As with all the previous meetings, apart from the opening prayers and opening remarks, there was no structure to the meeting, no agenda, no targets stated, no outcomes reported. As usual in all previous meetings it was open “town meeting style” with contributions solicited from the floor. A number of delegates expressed their displeasure at the fact that Nigeria did not have an exhibition stand at the conference in direct contrast to many other African countries. This, they opined had robbed the country of the opportunity to showcase some of the achievements the country had made in tackling HIV. Concerns were also expressed at the absence of Nigerian official presence at key press briefings such as the one on PEPFAR and the presentation of what some argued was dated research by the Physicians for Human Rights on attitudes of Nigerian healthcare workers to people living with HIV.

As in all such meetings, at the end contact details for all those present were collected by the NACA staff who promised to get in touch with every one after the conference. Have they been in touch with you?

This time, we know that NACA is planning another meeting in well as a satellite meeting to give people an opportunity to engage with Nigeria. There will be a Nigerian stand. There is even a pre-conference meeting! We are hopeful this time that it will be different. That there will be an open diualogue with Nigerians. That we will hear how many Nigerians are actually on ARVs. How the PMTCT programme is saving lives. How and where the prevention activities are going on.

How, where, much!? We will ask the hard questions! It cannot be business as usual. So we appeal to NACA to keep the speeches short and answer our questions in Mexico!

We hope to hear from a NACA truly accountable to the Nigerian people.

If you are not there...we will let you know how it goes!

Monday, 21 July 2008

Preparing for Mexico: Another International AIDS conference

by chikwe ihekweazu and ike anya

Every other year, the HIV/AIDS ‘community’, an odd mixture of scientists, youth, community workers, activists, politicians, and various others gather in one city in the world for one of the largest conferences related to an area of scientific endeavor. The inspiration of community effort found in rallying and supporting science to overcome one of the biggest health issues of our time; HIV/AIDS were primary motivating factors in drawing many of us into the public health arena. Between Ike and myself we have attended all the conferences in the recent past; Durban where it started for us…with its powerful theme “Break-the-Silence”, Barcelona and the lunch of the ambitious “3 by 5” initiative, Bangkok and the euphoria of ABCs, Toronto when it was finally “time to deliver”...

Now its time for the next one in Mexico: themed "Universal Action Now!"

from the 3rd to 8th of August.

We will share out thoughts in this regard in a series of posts leading up to the conference.

Two years ago we were at another AIDS conference in Toronto. We were told it was "time to deliver" but it was not good news. 25 years on, with close to 40 million people infected, mostly resident on our continent, it was impossible not to feel guilty on how it had all come to this. Often as members of the “scientific community”, with our self gratifying altruistic attitude, we are all too quick to imagine that we can come up with quick solutions to new health challenges of our times. But this has defied us all. Peter Piot’s remarks during the opening ceremony were poignant;

“in an exceptional crisis, we must learn to act in exceptional ways”.

In these conferences, we attend less in search of new science as these will be published in journals anyway, but to seek some motivation to keep on believing and working. But it is hard in these AIDS conferences, it is hard…especially as an African: I cannot forget the words of this Ugandan lady:

“I abstained before marriage, I was faithful in marriage and still I became infected with HIV”.

It became obvious to many during the conference that our celebrated ABC strategy of “Abstain, Be Faithful and Use a condom” was failing African women. Regretfully, we had come to the painful realisation that men cannot be relied on to take the decision to “abstain”, “be faithful” or “to use a condom. Women were bearing the brunt of this epidemic, getting infected earlier, caring for the sick and elderly.

In Toronto Bill Gates made his appearance on the podium for the first time at one of these AIDS conferences. He announced his intention to give up day-to-day running of Microsoft, a company that has revolutioni zed our way of life, and devote the rest of life into work for his foundation: The Bill and Melinda Gates Foundation. It is now one of the largest funders of research into health issues in the world. I could not help but think; in 10 years time Bill Gates might be remembered less for his role in the growth of information technology but for the public health issues. Maybe the man was in the process of redefining his legacy…just maybe. Could Microsoft become a footnote in the Bill’s legacy?

As usual, in the midst of despair, there were some success stories and ground for careful optimism. Botswana went against the norm and introduced universal testing in 2004. This policy requires that each person who attends a hospital to be tested for HIV unless he/she actively opts out. Botswana’s argument was that the requirement for extensive counseling prior to testing, a legacy from the era when treatment was inaccessible to most of those infected was now an impediment for universal access to treatment. Many in the ‘international community’ remained skeptical. We heard that in 2 years, this new policy led to an increase from 18 to 25% of people who are aware of their HIV status in Botswana. In a Satellite session organised by Botswana a nurse summarised her emotions as follows;

“I cannot continue burying my friends while we insist on voluntary counselling before testing, if I wanted to be an undertaker, I would not have trained as a nurse”.

One of the most interesting sessions at the conference held on the Wednesday afternoon, titled “25 years of AIDS reflecting back, looking forward”. The panel included Antony Fauci and Peter Piot and was chaired by Richard Horton, the Editor of the pre-eminent medical journal, “The Lancet”. Most of us Nigerians is this session as we were in our bi-annual, mid-conference moaning session, a meeting of sorts where we all come to cry our eyes out to the leaders of the official delegation (more on this in subsequent posts!). We knew it would be a difficult call to miss this session, but patriotic instincts can be so strong. Anyway, thanks to the marvels of modern day technology, we quickly rushed to the net to catch the webcast as soon as it became available. Richards opening remarks were poignant and profound. We felt like our country was were being addressed directly when he asked:

“Why are we not using these meetings as a global accountability mechanism for country progress, to hold everyone of us accountable for what we have done in the previous 2 years, and set specific, measurable objectives for the next 2?”

On ARVs and the hope it offers for Africa, Kevin DeCock, director of the WHO Department of HIV/AIDS warned;

“We cannot treat our way out of this epidemic, continuing at the present pace, there will be 450,000 new cases on treatment each year yet there’ll are 4 million new infections”.

Many scientists moan at the lack of scientific rigor at these AIDS conferences. We will argue that it is just as important that this conference is open to a wide variety of people from all backgrounds. I remember the conference in Durban, in 2002. The motivation to pursue a career in “public health” was created less by the over-whelming science than by the inspiration of people like Zachy Achmat of the Treatment Action Campaign. At the time it was considered almost insane to imagine that ARVs, then costing about $10,000 per person, per year would ever be available to treat people living in Africa. Yet Zachy and his group believed and convinced us that it was possible. Today we have seen that it is possible. This was not achieved by science!

History will not judge us by our scientific advances but what we do with them.

Where will we be in 25 years time? A quick death from pandemic influenza or a slow one from HIV/AIDS? Hopefully, none of the above will come to pass.

At the end of the conference, Peter Piot, the Director of UNAIDS repeatedly said,

"...we know what works….what remains is the will....!"

What do Nigerians think?


Monday, 14 July 2008

Lagos State...really leading the way

Much has been written about the new Government of Lagos State under its unlikely Governor Babtunde Raji Fashola. Much has been said about the intriguing circumstances that threw up this non-politician to governance...and how this act of fate seems to be transforming Lagos State. But the health sector, its never really been on any one's agenda...

At best, we hear about hospitals being built, BIG hospitals! The bigger the better! It has been difficult to make the argument to people that a BIG hospital does not improve any one's health! Health care is about identifying the health problems of a population, designing an integrated health care service (primary, secondary and tertiary) to provide these services, and managing it accordingly. Having a BIG building does nothing of the above!

When I read the first stories about 5 new 100 bed hospitals being built in Lagos state, it did not attract any attention until I read that further that these were specifically Maternal and Child Health complexes. All were being built in the grounds of already existing hospitals. I read the infant mortality rates and maternal mortality rates being quoted. I read that the hospitals are being built as part of an integrated four-year infrastructure development plan for health care.

It was obvious that someone was thinking in Lagos State!

Then came the next surprise; the press was reporting that the Lagos State government has shut down 184 private hospitals, clinics and laboratories for failing to meet basic standards of hygiene and staff training! Hygiene? In Lagos State?
A government official was quoted to say ; "Corruption, mismanagement and poor leadership are the main problems of the health system in Nigeria,"... "These have been recognized by the Lagos State government which is... tackling these issues through a reform process of which regulating the private sector is a key initiative." Regulating the private sector?

someone really is thinking in Lagos State!

Then came a story that really blew my mind: The Lagos State Government was threatening to sack its health sector workers for ....wait for this...public criticism of the attitudes of some health workers in the state hospitals and other health facilities. The State Commissioner for Health made this threat while on an impromptu monitoring visit to some general hospitals in the State.

someone is thinking in Lagos State!

Lets hop
e it spreads to other states :)

Want to know the public hospitals in Lagos State, there opening times, here

Lagos University Teaching Hospital?... click here

A listing of private hospitals? here

Kudos to the Government of Lagos State, we hope that slowly but steadily health will return to the agenda of Governance in the country!


Tuesday, 8 July 2008

Bring Back the Community Health Clinics!

While we wait for all the new Health minister and the anticipated utopia that would follow, it would be nice to add more issues to her to do list.

Growing up in a very rural part of Nigeria, our only source of health care was a "dispenser". This man/woman probably a well trained nurse practitioner now that I think about it. He was the-go-to person for all health issues that could not be resolved by the traditional medicine men and herbalists who reigned supreme in our environment.

I remembered clearly when i had close to a second degree burn,how he nursed me back to health, I remembered several other visits to the health center for varied ailments, immunizations, and even visit to see newborn babies in the nearby maternity.

As medical students we were bussed to community health clinics for 4week long rotations, more like fact finding missions and not direct patient care/ contact events. it was good while it lasted, the memories still linger.

Learning they say is a continuum, and I have adapted my learning to look only at things that work and see how it can be improved on, while balancing the act of not re-inventing the wheel.

This week I had the opportunity of wandering into a community health clinic run completely by residents and volunteers ( volunteerism in Nigeria that is a topic for another day). It took me back to my childhood.

Community health clinics run by residents: could this work in our environment?, Is this a model that we could look more closely at. On further investigation, I found out that the residents had to transport themselves to these clinics ( about 25miles away from their primary hospital), 4 residents rotate for three years every Monday from 1:00-5:30pm or until all the patients are seen whichever comes first.

So many community health models abound, and there is no need to re-invent the wheel, rather we should use what works modified for our environment.

Dr Paul Farmer for so many years have also worked on his model of community health clinics,in so many countries, Haiti, Peru, Rwanda, USA, Russia. Now "THE MODEL" of community health clinics. Read more at . He has training manuals, budget information, evaluation materials and so many information about setting up a successful community health clinic, absolutely FREE for all comers, this can be accessed at .

Knowledge they say is power, now the new health minister would not have any reason for failing our under served population, whenever he/she comes on board.

Wednesday, 2 July 2008

MSF and Nigeria...joint at birth

by chikwe ihekweazu

I recently attended the Scientific Day of Medecins Sans Frontieres (Doctors without boarders) in London where they presented some of the good work they do around the world. MSF is probably the best known non-governmental organisaton in the world and their good work was rewarded with the Nobel Peace Prize in 1999...and needs no further introduction.

What many might not know is the the role of the one of the saddest parts of our history; Nigerian/Biafran war in the formation of MSF.

The Nigerian/Biafra war was particularly hard on the civilian population because of food blockades, and massive flows of refugees and internally displaced persons under very precarious circumstances. The Red Cross managed to send some 50 doctors to Biafra. These doctors were driven by a desire to use their professional skills to save as many lives as possible. Among those 5o doctors that sacrificed so much for the survival of our people were the future founders of MSF, including Bernard Kouchner, who later became France's former Minister of Health and present foreign minister.

The Biafran war clearly revealed the shortcomings of the Red Cross in responding to emergencies. Some of the future founders of MSF opposed Red Cross regulations that forbade the Red Cross staff from making public statements about human rights violations and genocide. ICRC was not entitled to intervene in a country without the approval of the country's authorities. Several Red Cross doctors defied this prohibition by organizing a "committee against the Biafran genocide" as soon as they were back in France.
The committee argued that medical action should not
be turned into a blind and dumb instrument.
This activity attracted a group of approximately fifty people who were persuaded that conflicts such as Biafra would happen again (how right they were) and needed to be anticipated. Thus, the Biafra veterans began meeting once a month to share and refresh their memories....and the MSF story began. Read details here. Today, MSF's work is based on the principles of impartiality, operates independently of any political, military, or religious agendas...and most importantly in my opinion commits to Bearing Witness & Speaking Out.

MSF has been working in Nigeria for many years. They ran a Malaria programme in the heart of the Niger Delta as the Nigerian Government and its buddies in the oil industry ignored the people. MSF has been in the lead of the response to almost all outbreaks of infectious disease in Nigeria and notable has been the first to respond to the cycles of Menigitis outbreaks in Northern Nigeria. When HIV/AIDS emerged, MSF again was one of the first organisations that set up treatment centres in the heart of Lagos serving the most underprivildeged in society. Read this incredible story by one of the doctors that volunteered their time...HERE. Presently...they are helping us deal with gunshot wounds at MSF’s Port Harcourt trauma centre.We Nigerians have a lot to be thankful for! Rather than spend their energy and scarce resources on countries that are really poor, they help a country that is extremely rich but has decided to abdicate its responsibility to provide for the health of its population.

I digress...back to the conference.

In a presentation titled "Viral load testing in resource-limited settings: the devil is in the detail. Experiences from Lagos". the presenter used carefully chosen terms to describe the huge challenges MSF faces with the laboratories it relies on for the testing that needs to accompany antiretroviral therapy for people with HIV. These included "poor quality control" "poor technique" etc...and concluded that ....this has significantly delayed and inhibited the operational research ambitions of the project. a subtle tone she mentioned the huge challenge of running complex tests in an environment where electricity cannot be guaranteed for an uninterrupted 1 hour stretch!
So...this puts into context for me the last governments priority of equipping our teaching hospitals with state of the art diagnostic equipment....when the "simplest" of tests are impossible in our setting. Yes The devil is in the detail....

Ill conclude by saying THANK YOU for all those that choose to give up their time and resources to work for MSF in Nigeria.
If I was European...and decided to work for MSF...would I choose Nigeria? Hell no! I would go to Tanzania, to Ghana, to of those beautiful countries where one can really look at the African sunset after a hard day at work. Not so in the heart of Lagos, Bayelsa or Kano where MSF works...

So ...thank you folk!
The rest of not really have a choice...Na Naija get us!