tag:theconversation.com,2011:/au/topics/africa-health-19290/articlesAfrica health – The Conversation2024-03-12T10:29:52Ztag:theconversation.com,2011:article/2248912024-03-12T10:29:52Z2024-03-12T10:29:52ZWhat’s behind the worldwide shortage of cholera vaccines? For starters, they’re only made by one company<p><em>In February 2024 the World Health Organization announced southern Africa was suffering the deadliest <a href="https://www.savethechildren.net/news/southern-africa-four-fold-surge-cholera-cases-puts-tens-thousands-children-risk-cyclone-season">regional outbreak</a> of cholera in at least a decade. At the epicentre of the disaster were Malawi, Zimbabwe and Mozambique, where cholera cases surged more than <a href="https://www.savethechildren.net/news/southern-africa-four-fold-surge-cholera-cases-puts-tens-thousands-children-risk-cyclone-season">four-fold</a> between 2022 and 2023. Over 1,600 deaths were reported in the three countries.</em></p>
<p><em>Already 2024 is threatening to be another devastating year for cholera in the region as warmer weather and unusually heavy rains and storms have fuelled the disease’s spread. Zimbabwe, Mozambique and Malawi have reported more than <a href="https://www.savethechildren.net/news/southern-africa-four-fold-surge-cholera-cases-puts-tens-thousands-children-risk-cyclone-season">13,000</a> cases of the disease so far in 2024.</em></p>
<p><em>Cholera bacteria are spread by eating or drinking food or water contaminated by the faeces of an infected person. Oral vaccines help contain outbreaks and limit the spread of the disease. But there is a worldwide shortage of the vaccines.</em></p>
<p><em>From January 2023 to January 2024 there were urgent requests for <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)00467-7/fulltext">76 million doses</a> of the oral cholera vaccine from 14 nations. Only 38 million doses were available. Stockpiles <a href="https://reliefweb.int/report/world/global-cholera-vaccine-stockpile-runs-empty-16-countries-report-outbreaks">ran dry</a> at the beginning of 2024.</em></p>
<p><em>Nadine Dreyer spoke to vaccinologist Edina Amponsah-Dacosta about the impact of the vaccine shortages and what is being done to secure stockpiles for future outbreaks on the continent.</em></p>
<h2>The world’s oral cholera vaccine stockpile has run dry. Why?</h2>
<p>Unlike routinely administered vaccines, such as those for measles, the cholera vaccine is developed on a needs basis: during outbreaks and humanitarian crises, for example. </p>
<p>There’s <a href="https://www.pih.org/article/why-global-cholera-vaccine-shortage-goes-unnoticed-despite-high-demand#:%7E:text=There's%20limited%20funding%20to%20purchase,by%20EuBiologics%20in%20South%20Korea.">limited funding</a> to purchase cholera vaccines, and as a result there’s limited production. </p>
<p>There is only one vaccine recommended for mass vaccination during cholera outbreaks, <a href="http://eubiologics.com/eng/sub2_1.php">Euvichol-Plus</a>.</p>
<p>The vaccine is manufactured exclusively by EuBiologics, a global biopharmaceutical company based in Seoul in South Korea.</p>
<p>The company has limited manufacturing capacity. So when there is a spike in the need for the vaccine, demand outstrips production.</p>
<p>So there is usually only a limited stockpile available. </p>
<p>Traditionally we haven’t had several countries experiencing outbreaks at the same time like we are currently seeing in <a href="https://www.afro.who.int/health-topics/disease-outbreaks/cholera-who-african-region#:%7E:text=Since%20the%20beginning%20of%20the,case%20fatality%20ratio%20of%202.4%25.">southern and eastern Africa</a> as well as in parts of the <a href="https://who-global-cholera-and-awd-dashboard-1-who.hub.arcgis.com/">eastern Mediterranean, the Americas and south-east Asia</a>.</p>
<p>This is one of the main reasons for the current shortage.</p>
<p>EuBiologics has identified certain steps in the manufacturing process that could be refined and shortened, while ensuring that the vaccine remains safe and effective.</p>
<p>A low-cost, simplified version, <a href="https://www.ivi.int/euvichol-s-simplified-formulation-of-oral-cholera-vaccine-licensed-by-korean-regulatory-agency/">Euvichol-S</a>, has been approved by the World Health Organization and will help ease the shortage. Over 15 million doses of Euvichol-S are expected in 2024. </p>
<h2>What is being done about the vaccine shortage in southern Africa?</h2>
<p>There have been several strategies to fight the outbreak.</p>
<p>Firstly, in October 2022 the <a href="https://www.who.int/news/item/19-10-2022-shortage-of-cholera-vaccines-leads-to-temporary-suspension-of-two-dose-strategy--as-cases-rise-worldwide">WHO temporarily suspended the standard two-dose vaccination regimen</a> in favour of a single dose to stretch existing supplies.</p>
<p>Two doses provide up to two or three years’ protection, but one dose is still safe and effective. With one dose we’re able to deliver some level of safety up to one year or just a little bit more, hopefully enough time to beat the current outbreaks.</p>
<p>Secondly, countries like Zambia and Zimbabwe have taken steps to prioritise vaccine distribution to areas that need them the most. </p>
<p>An example of a priority area would be one devastated by droughts or floods with a high transmission rate and no access to safe drinking water and sanitation.</p>
<p>Last year, cholera cases surged in Malawi and Mozambique following <a href="https://www.savethechildren.net/news/southern-africa-four-fold-surge-cholera-cases-puts-tens-thousands-children-risk-cyclone-season#:%7E:text=Last%20year%2C%20cholera%20cases%20surged,and%20ended%20in%20mid%2D2023.">Cyclone Freddy</a>, the longest-lived tropical cyclone in history. It traversed the southern Indian Ocean for more than five weeks in February and March. </p>
<h2>Is progress being made to develop more cholera vaccines?</h2>
<p>In Africa less than <a href="https://www.dst.gov.za/index.php/media-room/latest-news/4149-boosting-local-vaccine-manufacturing-capacity#:%7E:text=Africa%20produces%20less%20than%201,critical%20vaccines%20to%20save%20lives.">1%</a> of doses of all vaccines are locally manufactured.</p>
<p>During the COVID-19 pandemic African countries were forced to the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276532/">back of the queue</a> for life-saving COVID-19 vaccines. It taught us that we need to have our own local manufacturing capacity.</p>
<p>In the case of cholera we are seeing that we cannot rely on just one manufacturer in South Korea when most of the outbreaks are happening in several African countries.</p>
<p>The problem has been recognised and there are steps to rectify it. There has been a lot of investment in expanding the cholera vaccine manufacturing <a href="https://www.dst.gov.za/index.php/media-room/latest-news/4149-boosting-local-vaccine-manufacturing-capacity">capacity</a>. </p>
<p>Two manufacturers are coming into play globally, one in South Africa and one in India.</p>
<p><a href="https://www.ivi.int/biovac-signs-deal-with-ivi-to-develop-and-manufacture-oral-cholera-vaccine-for-african-and-global-markets/">Biovac</a>, a biopharmaceutical company based in Cape Town, has received investment capital to develop vaccinations for cholera and other diseases.</p>
<p>It has concluded a ground-breaking licensing and technology transfer agreement with the <a href="https://www.biovac.co.za/wp-content/uploads/2022/11/Biovac-IVI-OCV-Technology-Transfer-Press-Release-23-Nov-2022.pdf">International Vaccine Institute</a>, a non-profit international organisation headquartered in South Korea, for the manufacture of the vaccine.</p>
<p>The first batch of vaccines will undergo clinical trials from 2024 to 2025, with licensing expected from 2026. This means we won’t see locally manufactured cholera vaccines until after 2026.</p>
<p>In India, pharmaceutical company <a href="https://www.science.org/content/article/world-s-stockpile-cholera-vaccine-empty-relief-way">Biological E</a> plans to manufacture the simplified version of Euvichol-plus. </p>
<p>But vaccination is not a replacement for the provision of safe drinking water, adequate sanitation and good hygiene practices.</p><img src="https://counter.theconversation.com/content/224891/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Edina Amponsah-Dacosta receives research funding through Gilead Sciences' Research Scholars Program. </span></em></p>The world’s stockpile of cholera vaccines has run dry, bad news for cholera-ravaged southern Africa. Why is this and what is being done to address vaccine shortages in Africa?Edina Amponsah-Dacosta, Research Officer / EIDM Specialist, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/836542017-09-13T17:01:30Z2017-09-13T17:01:30ZWhy the path to longer and healthier lives for all Africans is within reach<figure><img src="https://images.theconversation.com/files/185864/original/file-20170913-20326-ht66a0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sub-Saharan Africa can achieve meaningful and sustainable change in health by 2030.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There is huge diversity within and across the 49 countries in sub-Saharan Africa. The challenges these countries face in achieving health outcomes that are at par with low and middle income countries in other regions of the world are numerous and diverse. But they are not insuperable.</p>
<p>The future of health in sub-Saharan Africa is the focus of a <a href="http://www.thelancet.com/commissions/future-health-Africa">new major report</a>, “The path to longer and healthier lives for all Africans by 2030”. This Lancet Commission report is the culmination of more than four years of work among leading African academics, researchers, policymakers, business leaders, civil society organisations, and non-African collaborators.</p>
<p>The Lancet Commission believes:</p>
<blockquote>
<p>that by 2030 Africans should have the same opportunities for long and healthy lives that new technologies, well-functioning health systems, and good governance offer people living on other continents.</p>
</blockquote>
<p>To achieve this, the report offers 12 strategic directions that all sub-Saharan countries should consider in their policies and plans. These include the promotion of health, prevention of disease, and expansion of access to treatment and care. While these 12 options apply to all countries in sub-Saharan Africa, each country must adapt these in line with its specific needs, resources and culture. </p>
<p>The researchers call on countries to build on homegrown solutions to sustain improvements in health outcomes. Central to these is investment in higher education and research. The report argues that:</p>
<blockquote>
<p>local research is the main way to identify challenges, set priorities, devise solutions, and make the best use of limited resources. Local research is also needed to understand and address health priorities, service problems, and socio-cultural issues of vulnerable groups. </p>
</blockquote>
<p>The gap between sub-Saharan Africa and other regions of the world is most accentuated in terms of research and higher education. The region not only has a <a href="http://www.universityworldnews.com/article.php?story=2014100213122987">critical shortage of researchers</a> but a large percentage of researchers spend less than two years in African institutions. Most of these researchers leave to become experts on Africa in the countries where much of the research monies come from.</p>
<p>But the report argues: </p>
<blockquote>
<p>Sub-Saharan countries have unprecedented opportunities to substantially improve health outcomes within a generation, largely with their own resources. </p>
</blockquote>
<h2>Funding for research</h2>
<p>Sub-Saharan Africa invests the least in funding for research. No country in the region invests up to 1% of its GDP in research and development compared to a <a href="http://databank.worldbank.org/data/reports.aspx?source=world-development-indicators">global average of 2.12%</a>. In some countries like South Korea and Israel, this percentage is above 4%. </p>
<p>Much of the research in sub-Saharan Africa is through international collaborations. Such collaborations accounted for <a href="http://documents.worldbank.org/%20curated/en/2014/09/20240847/decade-development-sub-saharan-african-science-technology-engineering-mathematics-research">79% of East African research output in 2012</a>. Most importantly, these collaborations are almost always with non-African partners and involve unequal partnerships. Research collaborations among African institutions account for less than <a href="https://www.researchgate.net/profile/Omwoyo_Onyancha/publication/220364578_Knowledge_production_through_collaborative_research_in_sub-Saharan_Africa_How_much_do_countries_contribute_to_each_other%27s_knowledge_output_and_citation_impact/links/0c960527144135b9b6000000/Knowledge-production-through-collaborative-research-in-sub-Saharan-Africa-How-much-do-countries-contribute-to-each-others-knowledge-output-and-citation-impact.pdf">3% of Africa’s total research output</a>.</p>
<p>There has been massive growth in the number of higher education institutions in SSA. Student enrolment in Africa is also increasing rapidly, especially at the undergraduate level. But there has not been corresponding growth in levels of <a href="http://siteresources.worldbank.org/EXTAFRREGTOPEDUCATION/Resources/ACU_Synopsis_ENG_TYPESET_RIGHT.pdf">funding, staffing, facilities and infrastructure</a> in higher education. This has generally undermined the quality of university education, especially postgraduate education. </p>
<p>As part of the renewal of African universities, some have called for differentiation of universities in which a few focus more on research and postgraduate training. <a href="http://www.aaionline.org/wp-content/uploads/2015/09/AAI-SOE-report-2015-final.pdf">As the Commission report noted</a>, </p>
<blockquote>
<p>Fifteen universities from eight countries have formed the <a href="https://www.news.uct.ac.za/article/-2015-03-12-african-research-universities-alliance-launched">African Research Universities Alliance</a>, with the aim of strengthening research and postgraduate training in Africa.</p>
</blockquote>
<p>Despite these challenges, African research is on the ascendancy. Health research accounts for much of the growth in research output, often reflecting the priority of external funders of research. Between 2000 and 2014, sub-Saharan Africa achieved a <a href="http://documents.worldbank.org/curated/en/2014/09/20240847/decade-development-sub-saharan-african-science-technology-engineering-mathematics-research">growth of 251%</a> in research output compared to 96% globally. </p>
<p>While impressive, this also reflects the very low base of Africa’s contribution to global knowledge production. The continent currently accounts for <a href="http://en.unesco.org/node/252282">only 2·6% of the world’s output</a> of scientific papers. Most of this output is from South African universities.</p>
<h2>Africans must take the lead</h2>
<p>The Commission report underscores the need for Africans to take the lead on the health, scientific, and development challenges in close collaboration with the global research community. It offers several recommendations to strengthen research and higher education sector, which among others, include:</p>
<ul>
<li><p>Each country to develop a 10 to 20-year strategic plan for national health research. This should be coupled with a financing strategy for creating and strengthening departments and institutions responsible for all areas of research.</p></li>
<li><p>Increase research and development funding to at least 1% of GDP and to</p></li>
</ul>
<blockquote>
<p>allocate at least 2% of national health expenditure and at least 5% of external aid for health projects and programmes to research and research capacity building’.</p>
</blockquote>
<ul>
<li><p>Invest in internationally competitive centres of scientific excellence and expand post-doctoral programmes to raise the quality of higher education and research.</p></li>
<li><p>Expand research and education collaborations, particularly within Africa, and reshape international research partnerships around mutual agenda setting and benefit.</p></li>
<li><p>Academic institutions in sub-Saharan countries to invest in the development of contextually relevant health sector governance and leadership programmes.</p></li>
<li><p>Finally, the report recommends that international agencies should support the strengthening of higher education and research institutions by incorporating core funding and removing arbitrarily low caps on overheads on project grants.</p></li>
</ul>
<h2>Research collaboration</h2>
<p>With the lack of critical mass of skilled researchers in many African countries, strengthening regional research collaboration could be a strategic priority for the region. </p>
<p>African countries could consider creating a basket of funding for research which countries could contribute to. Researchers within the contributing countries would then compete for funding from the pool. Development partners can be invited to provide matching funds thereby increasing the size of the basket. </p>
<p>The African Development Bank or some other continental body could centrally manage the funds and underwrite the associated administrative costs. Further requirements can be introduced. For example, applications could be limited to collaborative research involving researchers from at least two countries or sub-regions. Preference could also be given to applications with collaborators from countries with weak national research systems. </p>
<p>These measures, together, will represent “a serious shift in mindsets”, which the commissioners argued is key to achieving meaningful and sustainable change in health in sub-Saharan Africa.</p><img src="https://counter.theconversation.com/content/83654/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alex Ezeh receives funding from Sida, Wellcome Trust, Carnegie Corporation of New York, Hewlett Foundation.
Alex Ezeh is affiliated with School of Public Health, University of the Witwatersrand, South Africa as Honorary Professor.
Alex Ezeh is Co-Director of the Consortium for Advanced Research Training in Africa (CARTA).</span></em></p><p class="fine-print"><em><span>Peter Piot is the Director of the London School of Hygiene & Tropical Medicine. Peter Piot has received funding from the UK Department for International Development, the Joint United Nations Programme on HIV/AIDS, the King Baudouin Foundation, the Handa Foundation and from the Bill & Melinda Gates Foundation .</span></em></p><p class="fine-print"><em><span>Nelson Sewankambo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Sub-Saharan countries have unprecedented opportunities to substantially improve health outcomes within a generation, largely with their own resources.Alex Ezeh, Executive Director, African Population and Health Research CenterNelson Sewankambo, Professor of Internal Medicine, Makerere UniversityPeter Piot, Director and Handa Professor of Global Health, London School of Hygiene & Tropical MedicineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/784122017-05-26T10:04:28Z2017-05-26T10:04:28ZThree ideas on how the new WHO DG can build health systems from the bottom up<figure><img src="https://images.theconversation.com/files/171111/original/file-20170526-23230-mof293.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tedros Adhanom Ghebreyesus, the new Director-General of the World Health Organisation </span> <span class="attribution"><span class="source">Reuters/Denis Balibouse</span></span></figcaption></figure><p>Dr Tedros Ghebreyesus Adhanom is <a href="http://www.who.int/mediacentre/news/releases/2017/director-general-elect/en/">the first African</a> to become the director-general of the World Health Organisation (WHO). He is also the first non-physician to head up the United Nations’ body.</p>
<p>He has big challenges ahead of him.</p>
<p>He will be expected use his formidable talents – including diplomacy – to boost the WHO’s image and finances, protect it against the whimsical policies of superpowers, and keep the organisation free of <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31146-7/fulltext">commercial influences</a>. </p>
<p>Dr Tedros has already prioritised improving <a href="http://www.bbc.co.uk/news/amp/40010522">universal health coverage</a>. As he put it:</p>
<blockquote>
<p>All roads should lead to universal health coverage. I will not rest until we have met this.</p>
</blockquote>
<p>To achieve this, he will need <a href="http://www.healthsystemsglobal.org/vision/">to strengthen health systems</a>. But the challenge he faces is that the responsibility for strengthening health systems is different in different contexts, and it seldom falls directly to the WHO. </p>
<p>Such efforts are often driven by funders’ priorities. And for countries that don’t rely on external resources, such as China and India, investments in health systems tend to reflect domestic social sector policy and priorities. </p>
<p>It’s therefore worth asking: what can the WHO, or more specifically the DG, do to advance the health systems agenda? Here are three ideas that could be usefully pursued to achieve the outcome the DG desires.</p>
<h2>Span boundaries</h2>
<p>Much of global health activity is still organised into disease-specific silos. This can be insidious: it privileges narrow disease-specific solutions, when in reality more holistic systemic or political solutions may be in order. </p>
<p>The global response to the 2014 Ebola outbreaks provides a useful example to illustrate the problem. The outbreaks evoked fear of a global epidemic as thousands died in West Africa. As a result significant external resources were diverted to contain the epidemic, until it emerged that there were key missing links to the response – <a href="https://academic.oup.com/afraf/article-pdf/114/454/136/6645026/adu080.pdf">engaging local communities and strengthening local health systems</a>.</p>
<p>The Ebola case highlighted the fact that there is never one silver bullet when addressing health issues, even in a crisis. Similarly, health gains depend heavily on action across a range of development sectors such as the environment, food, urban development and gender equality. To maximise gains coordination across all of them is vital. </p>
<p>An example of how this can work is well illustrated in <a href="http://www.tandfonline.com/doi/pdf/10.1080/23288604.2016.1148802">Chhattisgarh, rural India</a> where the demands of marginalised tribal communities for better health care were part of a larger movement for access to water and conservation of forest resources. Community health workers frequently engaged in supporting people’s needs beyond the health sector.</p>
<p>Breaking the silos and promoting <a href="http://gh.bmj.com/content/1/1/e000058">boundary-spanning</a>, across disease programmes and between development sectors, is key to making the health sector more effective. The <a href="http://www.un.org/sustainabledevelopment/sustainable-development-goals/">Sustainable Development Goals</a> offer ample opportunity to broker alliances with other global agencies, but also for the WHO to help mainstream intersectoral action as part of health systems strengthening efforts at national and local levels.</p>
<h2>Diversify engagement with countries</h2>
<p>As the first DG from a member state that is also a major recipient of global aid, Dr Tedros will be acutely aware of the boundaries between support to a country, and respect for its self-determination. </p>
<p>It will be interesting to see how the WHO will help developing countries balance the results orientation of donors, with institution-building initiatives that are necessary yet might not yield short-term gains.</p>
<p>The WHO is a member state organisation. But it can’t neglect the fact that states don’t necessarily represent the interests of all their people. Ultimately the WHO has a responsibility to promote democratic values and to help people’s voices be heard, especially those of the most vulnerable. </p>
<p>People all over the world are concerned about governance, including the governance of health systems. The desire to be freed of corruption and exploitation, to have basic rights and entitlements, and to be able to have a say in their own future are universal. These issues must be addressed by the WHO. </p>
<p>The emerging <a href="https://t.co/NU4LSGb71x">Health Systems Governance Collaborative</a> at the WHO seeks to promote practical solutions and learning to improve governance at local and national levels. It is an interesting experiment that could extend WHO’s focus beyond the narrow domain of technical support, into complex real world health systems. But more such experiments are called for.</p>
<h2>Make global health about care, not fear</h2>
<p>A health system is, or should be, the institutionalisation of the basic human impulse to care. Its performance is a reflection of society’s will for caring. The WHO should manifest the global community’s collective commitment to caring – which translates practically into helping build caring institutions across the world. </p>
<p>The WHO can do more to support bottom-up practices: listening to voices of health system builders on the ground (particularly those engaged in caring for the poor), learning from and supporting them, and putting what they learn into practice and policy. </p>
<p>This change must be led by the DG as part of the organisational accountability reforms <a href="http://www.bbc.co.uk/news/amp/40010522">he has prioritised</a>.</p>
<p>Global health is often described as a lexicon of threats, whether from antimicrobial resistance, climate change or epidemics. Safety and security are certainly critical elements of the health systems agenda. But if the rhetoric of fear overcomes that of care, the best-resourced health system will be ineffective in delivering good health equitably. The dream of universal health coverage will be elusive.</p>
<p>The WHO has a key role in ensuring that questions of global health security are never divorced from inclusivity.</p><img src="https://counter.theconversation.com/content/78412/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kabir Sheikh is the chair of Health Systems Global and a member of WHO’s Health Systems Governance Collaborative.</span></em></p>The new director-general of the World Health Organisation has set universal health coverage as a priority. There are several ways to make headway with this goal.Kabir Sheikh, Joint Director, Research and Policy, Public Health Foundation of IndiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/638882016-08-15T09:00:46Z2016-08-15T09:00:46ZNew polio outbreak threatens Nigeria’s steady march to eradication<figure><img src="https://images.theconversation.com/files/134027/original/image-20160814-25472-4y22hq.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nigerian women who formed part of the country's previous polio immunisation campaign. </span> <span class="attribution"><span class="source">Global Polio Eradication Initiative</span></span></figcaption></figure><p><em>In 2012 Nigeria accounted for <a href="http://blogs.cdc.gov/global/2015/08/24/wipe-out-polio-in-africa-for-good/">more than half</a> of all polio cases worldwide. Within three years – and after a rigorous immunisation campaign involving more than 200 000 volunteers – the country was <a href="http://www.who.int/mediacentre/news/releases/2015/nigeria-polio/en/">removed</a> from the list of polio-endemic countries. Less than a year later two new cases of polio have been reported. This is a setback for a country that aimed to achieve polio free status by 2017. Professor Oyewale Tomori explains why Nigeria finds itself in this position.</em></p>
<p><strong>Why has there been a new outbreak of polio in Nigeria?</strong></p>
<p>Nigeria was removed from the list of polio endemic countries after a long and tortuous <a href="https://theconversation.com/why-nigeria-took-so-long-to-get-non-polio-endemic-status-44932">eradication campaign</a>.</p>
<p>But after attaining <a href="http://www.who.int/mediacentre/news/releases/2015/nigeria-polio/en/">non-polio endemic status</a> in September 2015, commitment waned and complacency set in. This was particularly evident at the levels of the national assembly, governors and local government area chairpersons. This complacency meant that polio eradication activities were no longer backed by adequate and timely counterpart funding at the state and local government area levels. This was despite a public and often <a href="http://www.thisdaylive.com/index.php/2016/07/24/buhari-pledges-timely-release-of-funds-for-polio-eradication/">vocal commitment</a> to polio eradication from Nigeria’s President Muhammadu Buhari. </p>
<p>As a result gaps remained in the quality of immunisation and surveillance activities. These were especially prominent in the country’s security compromised areas. </p>
<p>The wild poliovirus (type 1) isolates were recovered from residents in Gwoza and Jere local government areas in Borno state in northern Nigeria. Genetic sequencing suggests these isolates are most closely linked to the wild poliovirus type 1 that was last detected in the state in 2011.</p>
<p><strong>How far back does this set Nigeria in its progress to eradicate polio?</strong></p>
<p>When Nigeria was removed from the list of polio-endemic countries in 2015 it meant this was the first time the country had managed to interrupt transmission of wild poliovirus. It needed to have no new cases of the wild poliovirus reported for three successive years to finally attain a polio free status by 2017. </p>
<p>Countries have to go at least 12 months without a case before they can be considered for removal from the list of polio endemic countries. Polio-free status comes after three years without a case. </p>
<p>Although Nigeria can no longer be considered a polio endemic country analysis shows that the 2016 isolate is closely linked to a 2011 isolate. This means we were unable to detect the transmission.</p>
<p>The current outbreak has set Nigeria back by at least two years – provided that no wild polio virus is detected in the future. </p>
<p><strong>What has Boko Haram’s role been?</strong></p>
<p>The new polio cases in Nigeria were reported from children in areas of the country rendered inaccessible by Boko Haram insurgency. </p>
<p>The insecurity seriously hampered effective routine and special immunisation activities.</p>
<p>Many of the children in these areas could not be reached. So, vaccination programmes couldn’t be carried out.</p>
<p>In addition, inaccessibility also made it difficult to effectively investigate reports of acute flaccid paralysis cases. Acute flaccid paralysis is weakness in the limbs in children under 15. This signals the onset of paralytic polio, with more serious symptoms such as loss of muscle reflexes, severe muscle pain and spasms and loose or floppy limbs that are often worse on one side of the body.</p>
<p>Boko Haram has contributed significantly to the current situation by creating an environment of insecurity in the affected areas. </p>
<p><strong>What does Nigeria need to do now?</strong></p>
<p>The World Health Organisation has a set of <a href="http://apps.who.int/iris/bitstream/10665/43883/1/9789241580410_eng.pdf">International Health Regulations</a> which guide countries on how to limit the spread of diseases and public health risks. The organisation’s emergency committee has deemed the international spread of poliovirus a public health emergency of international concern. </p>
<p>Nigeria complied with the temporary recommendations issued under the regulations. This involved declaring the outbreak a national public health emergency. </p>
<p>The Federal Minister of Health and stakeholders drew up an emergency plan. Three rounds of special immunisation campaigns were carried out in the affected and surrounding areas. This was a bid to ensure that the situation was contained.</p>
<p>But the current security situation will adversely affect the implementation of the plan. The Ministry of Health will need to work closely with the country’s armed forces to ensure easy access and protection of health workers.</p>
<p>I believe the situation is serious enough for the <a href="http://www.polioeradication.org/Portals/0/Document/Aboutus/Governance/IMB/12IMBMeeting/4.2_12IMB.pdf">Presidential Task Force on Polio Eradication</a> to be convened urgently. It must agree on the positive commitment and active involvement of national assembly members, state governors and local government area chairpersons. It must also maintain the essential support of traditional and religious leaders, women’s organisations and community leaders. These groups all have a role to play in making Nigeria a polio free country. </p>
<p>Nigeria must focus on attaining polio free status over the next three years and concentrate less on prematurely celebrating victory. </p>
<p>Nigeria was eagerly looking forward to 2017 as the year it would attain polio free status. The clock has now been set to 2019.</p><img src="https://counter.theconversation.com/content/63888/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Oyewale Tomori does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A new polio outbreak in Nigeria has hampered the country’s efforts to be declared polio free by 2017.Oyewale Tomori, President, Nigerian Academy of ScienceLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/562052016-03-25T09:40:38Z2016-03-25T09:40:38ZThe other opioid crisis – people in poor countries can’t get the pain medication they need<figure><img src="https://images.theconversation.com/files/116393/original/image-20160324-17840-1018h1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hard to get. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-244226398/stock-photo-morphine-sulfate-pills-with-bottle-and-prescription.html?src=6k1Q_GIQBxQ8258IRKLelw-1-3">Morphine pills image via www.shutterstock.com.</a></span></figcaption></figure><p>There are two opioid crises in the world today. One is the epidemic of abuse and misuse, present in many countries but rising at an <a href="https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates">alarming rate in the United States</a>. The other crisis is older and affects many more people around the world each year: too few opioids. </p>
<p>Hospitals in the U.S. and Europe routinely prescribe opioids for chronic cancer pain, end-of-life palliative care and some forms of acute pain, like bone fractures, sickle cell crises and burns. But patients with these conditions in much of Asia, Africa and Latin America often receive painkillers <a href="http://www.nytimes.com/2007/09/09/world/africa/09iht-pain.4.7440327.html?_r=0">no stronger than acetaminophen</a>.</p>
<p>Many factors play into this crisis, but I would argue that the International Narcotics Control Board (<a href="https://www.incb.org/">INCB</a>), an independent monitoring agency established by the U.N., <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=10232633&fulltextType=RA&fileId=S089803061600004X">is a fundamental cause</a> of untreated pain in Asia, Africa and Latin America.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=486&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=486&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116395/original/image-20160324-17859-bnvbdl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=486&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A worker handles medicine in the Pharmacie de la Sante Publique warehouse in Abidjan, Ivory Coast. Opioid painkillers can be difficult to access in many parts of Africa.</span>
<span class="attribution"><span class="source">Thierry Gouegnon/Reuters</span></span>
</figcaption>
</figure>
<h2>Just how vast is the gap in pain relief?</h2>
<p>In 2009, the U.S., Canada and Europe accounted for 18 percent of global population, but <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">90 percent</a> of global morphine consumption.</p>
<p><a href="https://ppsg.medicine.wisc.edu/">The global gap in access to opioids has been growing</a> for a long time. In the U.S., consumption of morphine in 2013 was 32 times higher than in 1964 (increasing from 2.3 mg per person to 79.9 mg per person). In the same time period, morphine consumption in Tanzania only doubled to 0.15 mg person. In India in 2013, this figure was only 0.11 mg per person.</p>
<p>Per capita medicinal opioid consumption in Asia, Central America, the Caribbean and Africa <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">is far below</a> the INCB’s own minimum global standard. In countries and regions below this benchmark (set at 200 daily doses per million inhabitants per day), we can be certain that patients who need opioids for legitimate medical reasons do not receive them.</p>
<p>The INCB argues that poor countries have too few opioids because they <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">cannot afford them</a>. While there is a correlation between national income and national consumption of opioids, cost isn’t the principal issue. </p>
<p>Generic opioids are cheap. A generic 10mg immediate-release morphine sulfate tablet costs roughly <a href="http://journals.lww.com/anesthesia-analgesia/Abstract/2007/07000/Pain_Management__A_Fundamental_Human_Right.37.aspx">US$0.01 to produce</a>.</p>
<p>The main problem, <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=10232633&fulltextType=RA&fileId=S089803061600004X">I would argue</a>, is a policy based on the fear that increased use of opioids will inevitably lead to abuse and trafficking. Palliative care physician and ethicist Eric Krakauer calls this fear “<a href="https://dx.doi.org/10.3109/15360288.2010.501852">opiophobia</a>.” </p>
<p>The work of the INCB has been crucial in increasing this fear of opioids and promoting restrictive policies that continue to keep millions of patients in unnecessary pain.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/116274/original/image-20160323-28201-3gyzya.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Morphine has legitimate medical uses.</span>
<span class="attribution"><span class="source">Vaprotan, via Wikimedia Commons</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Fear of abuse drives ‘opiophobic’ policies</h2>
<p>The International Narcotics Control Board has two purposes: to prevent addiction and to ensure the availability of opioids for legitimate medical use. But since its founding in 1968, the INCB has focused almost entirely on combating drug abuse, while ignoring access to pain relief.</p>
<p>One way the INCB tried to prevent addiction was by writing so-called “model laws” that it encouraged countries to enact. One such <a href="https://www.unodc.org/unodc/en/data-and-analysis/bulletin/bulletin_1969-01-01_2_page002.html">law</a>, written in 1969, set controls on opioid prescription and distribution that were manageable for wealthier countries, but that would prove onerous in poor countries, particularly those with few doctors.</p>
<p>The Model Law stated, for instance, that opioids could be supplied only by doctors. This provision did not affect access to opioids in the United States or in other wealthy nations with many physicians. But many poorer countries, where doctors were scarce, relied on nurses and other kinds of practitioners to prescribe drugs. The model law made no allowance for this.</p>
<p>In addition, the Model Law stated that physicians who prescribed opioids inappropriately or who failed to keep full records should be subject to “the same prison sentences and fines as are inflicted under the Penal Code for housebreaking.”</p>
<p>INCB laws were promoted by the United Nations Fund for Drug Abuse Control (<a href="https://www.unodc.org/unodc/en/data-and-analysis/bulletin/bulletin_1971-01-01_2_page002.html">UNFDAC</a>), which was founded in 1970. The UNFDAC conducted training sessions for national drug-control administrators and law enforcement to stress the dangers of abuse. But, as I found in my research, the sessions rarely mentioned the importance of access to pain relief.</p>
<p>The model laws and training sessions helped inspire countries in Latin America, Asia and Africa to pass <a href="http://dx.doi.org/10.1017/S089803061600004X">new, more restrictive laws</a> during the 1970s and ‘80s. </p>
<p>For instance, in India, a 1985 law required hospitals to obtain so many licenses before each shipment of morphine that many stopped using the drug at all. Medicinal morphine consumption in India fell by 97 percent between 1985 and 1997. </p>
<p>In Panama, nurses were barred from prescribing opioids. Paraguay and Guinea-Bissau mandated long prison sentences for any doctor who could not produce documentation justifying every single pill prescribed over years of practice. Fearing these punishments, doctors avoided prescribing opioids, even when they were medically necessary.</p>
<h2>Countries underestimate opioid needs in response to INCB pressure</h2>
<p>The INCB also tried to prevent opioids prescribed to treat pain from being diverted into illegal markets by requiring every country to provide annual estimates of projected opioid needs for medical and scientific purposes. The INCB was responsible for approving these annual estimates, and tried to ensure that countries imported no more than the approved quantities. </p>
<p>Between the 1960s and the 1980s, <a href="https://books.google.com/books/about/Estimated_World_Requirements_of_Narcotic.html?id=O_8tAQAAIAAJ">INCB reports</a> chastised many nations in Africa, Asia and Latin America for making estimates that it considered too high.</p>
<p>A country that imported more opioids than the INCB had approved risked a costly stain on its international reputation. The INCB could even <a href="http://www.unodc.org/unodc/en/data-and-analysis/bulletin/bulletin_1962-01-01_1_page007.html">recommend that countries impose trade embargoes</a> on nations that produced or imported more opioids than it had deemed necessary. As a result, countries low-balled their estimates of future medicinal opioid requirements.</p>
<p>But the INCB didn’t judge these estimates based on actual medical need. Rather, <a href="https://books.google.com/books/about/Estimated_World_Requirements_of_Narcotic.html?id=O_8tAQAAIAAJ">it insisted</a> estimates should be based on the number of physicians in a country, a potentially misleading piece of data in parts of the world were doctors are in short supply, and nurses and other health care professionals fill the gaps and prescribe medicine. </p>
<p>The INCB worried that too many opioid prescriptions could lead to abuse. Indeed, this is a major cause of the current addiction crisis in the United States. But, in the countries where the INCB exerted the greatest influence, the bigger problem was that too few (rather than too many) opioids were being prescribed.</p>
<p>A 1989 report from the INCB and World Health Organization revealed that national estimates of future opioid need were often calculated based <a href="https://www.ncjrs.gov/pdffiles1/Digitization/141719NCJRS.pdf">on nothing more than previous years’ imports</a>. That report also quantified the extent of untreated cancer pain, estimating that “at least 3.5 million cancer patients” worldwide “suffer needlessly from pain.” </p>
<h2>The INCB is starting to change, slowly</h2>
<p>For many years, the only thing most countries heard from the INCB was that their estimates were too high. But in 1999, <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">the INCB announced</a> it would begin to contact governments that submitted “particularly low estimates” to encourage them to increase their imports.</p>
<p>And in 2010, the INCB agreed that countries with few doctors should <a href="https://www.incb.org/documents/Publications/AnnualReports/AR2010/Supplement-AR10_availability_English.pdf">allow nurses to prescribe morphine</a>, a reversal from previous policy recommendations. </p>
<p>But these small steps have not been enough to overcome the fear of opioids spread by decades of model laws and training sessions. The INCB’s recommendations continue to focus almost entirely on abuse.</p>
<p>For instance, a 2012 INCB <a href="https://www.incb.org/documents/Narcotic-Drugs/Guidelines/estimating_requirements/NAR_Guide_on_Estimating_EN_Ebook.pdf">report</a> stated that national requests to import opioids sufficient to address existing need might be denied if such imports might raise “the possibility of diversion or abuse.” </p>
<p>International meetings, especially the <a href="http://www.unodc.org/ungass2016/">United Nations Special Session on the World Drug Problem</a> in April 2016, should pay far more attention to untreated pain than they have in the past. </p>
<p>More recent estimates from the World Health Organization suggest that each year <a href="http://www.who.int/medicines/areas/quality_safety/ACMP_BrNote_Genrl_EN_Apr2012.pdf">5.5 million terminal cancer patients</a> and 1 million end-stage HIV/AIDS patients around the globe don’t get enough treatment, or any treatment at all, for their moderate to severe pain. The WHO estimates that tens of millions of people are denied medically necessary pain treatment every year.</p>
<p>Pain is universal, but its relief is still a function of geography.</p><img src="https://counter.theconversation.com/content/56205/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Luke Messac does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Why are so many people in dire need of pain relief unable to access the powerful painkillers that are so commonly prescribed in the United States?Luke Messac, M.D./Ph.D. student in History, University of PennsylvaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/495982015-11-10T03:40:04Z2015-11-10T03:40:04ZNatural cancer remedies: sorting fact from fiction<figure><img src="https://images.theconversation.com/files/101259/original/image-20151109-29341-1ec67lb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Different parts of the guayabano or soursop plant has cancer-fighting properties. </span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>When it comes to natural remedies for cancer therapy, many patients are given anecdotal advice about the usefulness of alternative traditional medicines. They are also often told to combine these with their conventional medication for added effect.</p>
<p>While conventional treatments are subjected to rigorous research before they can be recommended for clinical use, alternative treatments are not. These “natural” remedies are either turned into over-the-counter medicines or can be taken in their natural forms. </p>
<p>It is important to note that alternative methods labelled “natural” are not necessarily “good”. Nor do they necessarily translate into healing. The use of traditional remedies should always be discussed with a physician or an oncologist. They may have adverse effects or may reduce the efficacy of conventional treatment.</p>
<p>Many alternative or traditional medicines <a href="http://www.cancer.org/acs/groups/cid/documents/webcontent/acspc-041660-pdf.pdf">claim</a> to have the ability to heal but there is <a href="http://www.cancer.org/acs/groups/cid/documents/webcontent/acspc-041660-pdf.pdf">no scientific evidence</a> to support this. In some cases scientific evidence may even <a href="http://www.cancer.org/acs/groups/cid/documents/webcontent/acspc-041660-pdf.pdf">contradict</a> the claims.</p>
<p>Here are some of the myths and facts about natural products that purportedly have anti-cancer properties.</p>
<h2>Fruit and vegetable pits</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/101264/original/image-20151109-29309-eul8jf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/101264/original/image-20151109-29309-eul8jf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/101264/original/image-20151109-29309-eul8jf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/101264/original/image-20151109-29309-eul8jf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/101264/original/image-20151109-29309-eul8jf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/101264/original/image-20151109-29309-eul8jf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/101264/original/image-20151109-29309-eul8jf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Chewing apricot pits were considered to have anti-cancer properties but this is not true.</span>
<span class="attribution"><span class="source">shutterstock</span></span>
</figcaption>
</figure>
<p>For generations the pits of many fruits, particularly apricots or kernels, have been promoted anecdotally to treat cancer. Traditionally the pits were chewed in their natural form. <a href="https://www.mskcc.org/cancer-care/integrative-medicine/herbs/amygdalin">Amygdalin</a> found inside apricot pits was thought to be the active ingredient linked to tales of its powerful anti-cancer properties. </p>
<p>But after nearly four decades of research, scientists cannot find any proof of its elusive chemotherapeutic effects. </p>
<p>What has been <a href="http://journals.lww.com/euro-emergencymed/Abstract/2005/10000/Severe_cyanide_toxicity_from__vitamin_supplements_.14.aspx">reported</a> and is nearly guaranteed is that a person who uses this remedy will suffer the adverse effects of chronic poisoning caused by the cyanide found in some of these pits.</p>
<h2>Overripe bananas</h2>
<p>In 2009, an <a href="https://www.jstage.jst.go.jp/article/fstr/15/3/15_3_275/_article">article</a> investigating cancer-related biological activity in ripened bananas was published. The study could not make any direct link to the fruit as an anti-cancer remedy but included the following statement:</p>
<blockquote>
<p>Due to the association between immunostimulatory and anti-oxidative effects, oral banana intake has the potential to help prevent lifestyle-related diseases and carcinogenesis. </p>
</blockquote>
<p>The statement went viral in the media with many memes posted on Facebook suggesting ripened bananas could reduce cancer risk. While <a href="http://libir.tmu.edu.tw/bitstream/987654321/50848/2/JECM_(2012)">studies</a> have demonstrated that antioxidants play an important role in protecting body cells against potential cancer agents, the article does not say bananas have an active ingredient that can combat cancer.</p>
<p>There are, however, remedies that have seen more positive results. </p>
<h2>The tropical guayabano fruit</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/101263/original/image-20151109-29326-flr22d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/101263/original/image-20151109-29326-flr22d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/101263/original/image-20151109-29326-flr22d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/101263/original/image-20151109-29326-flr22d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/101263/original/image-20151109-29326-flr22d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/101263/original/image-20151109-29326-flr22d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/101263/original/image-20151109-29326-flr22d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Different part of the soursop plant have anti-cancer properties.</span>
<span class="attribution"><span class="source">shutterstock</span></span>
</figcaption>
</figure>
<p>A member of the custard apple family fruit tree, <a href="http://dx.doi.org/10.3390%2Fijms160715625"><em>Annona muricata</em></a>, which is more commonly known as soursop, graviola or guayabano, is extensively eaten by indigenous communities in the tropical parts of northern Africa and South America. It is an oval-shaped, dark green, prickly fruit with a mildly acidic, whitish flesh. </p>
<p>When the plant was put through scientific tests, <a href="http://dx.doi.org/10.3390%2Fijms160715625">studies</a> found that several parts had potentially potent anti-cancer properties. This was particularly shown to be the case when used as an adjunct treatment.</p>
<p>Research showed that the leaves have active ingredients that possess anti-cancer properties that kill lung, prostate, colon, breast, and pancreatic cancer cells. Its seeds display properties that perform the same task that chemotherapy treatment would, killing breast, oral and lung cancer cells. And its fruit component has anti-prostate cancer potential. </p>
<p>Traditionally, the leaves and or roots would have been brewed or crushed for consumption, and the fruit eaten. But extracts of the active ingredients from the leaves have been made into tablets and sold <a href="http://ajouronline.com/index.php?journal=AJAS&page=article&op=view&path%5B%5D=1251&path%5B%5D=668">commercially</a>. These are taken in conjunction with conventional chemotherapy.</p>
<h2>South African rooibos herbal tea</h2>
<p>Rooibos, which is only found in the Cederberg region of the Western Cape, South Africa, is known for its aromatic flavour. The plant has been <a href="http://www.sciencedirect.com/science/article/pii/S1383571803003516">found</a> to have anti-cancer properties in <em>in vitro</em> and <em>in vivo</em> animal models. </p>
<p>Additional <a href="http://www.sciencedirect.com/science/article/pii/S0304383504008687">research</a> shows that the herbal tea possesses ingredients that reduce oesophageal and liver cancer and skin tumours. Clinical trials in humans are being planned. </p>
<p>The Cancer Association of South Africa has endorsed the herbal tea’s potential as a form of natural chemoprevention. This means it can aid in preventing cancer and even possibly reduce the growth of cancer cells. And it has funded <a href="http://www.cansa.org.za/rooibos-research-around-the-world/">research projects</a> aimed at identifying the active ingredients.</p>
<h2>The <em>Sutherlandia frutescens</em> plant</h2>
<p><em>Sutherlandia frutescens</em> is indigenous to South Africa, Lesotho, southern Namibia and southeastern Botswana. It is commonly used in traditional medicine. This shrub-like plant has bitter, aromatic leaves and is known for its red-orange flowers during spring to mid-summer.</p>
<p>Studies show that it has anti-cancer properties against <a href="http://www.sciencedirect.com/science/article/pii/S0378874111005307">oesophageal</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/26377232">prostate</a>, liver, <a href="http://www.sciencedirect.com/science/article/pii/S0378874111009238">breast</a> and lung cancer cells. Recent <a href="http://www.sciencedirect.com/science/article/pii/S0378874108004431">studies</a> proposed that cancer bush, the name it is commonly known by, may be a promising adjunctive therapy because of its potent anti-oxidative properties. </p>
<p>Preliminary <a href="http://www.ncbi.nlm.nih.gov/pubmed/25070435">clinical studies</a> proved that it had no negative effects. And the indications are that it may act as an immune stimulant to support the cancer patient. It has been made into tablet form and commercialised but studies are continuing to produce more definitive evidence of its benefits. </p>
<p>It is currently being marketed as a natural remedy that can be used alongside conventional treatment.</p>
<h2>Coix seed</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/101262/original/image-20151109-29317-fk5nk8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/101262/original/image-20151109-29317-fk5nk8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/101262/original/image-20151109-29317-fk5nk8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/101262/original/image-20151109-29317-fk5nk8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/101262/original/image-20151109-29317-fk5nk8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/101262/original/image-20151109-29317-fk5nk8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/101262/original/image-20151109-29317-fk5nk8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Extracts from coix seeds has anti-cancer effects.</span>
<span class="attribution"><span class="source">shutterstock</span></span>
</figcaption>
</figure>
<p>Traditional Chinese Medicine is a significant component of <a href="https://nccih.nih.gov/sites/nccam.nih.gov/files/Backgrounder_Traditional_Chinese_Medicine_10-25-2013.pdf">alternative medicine</a>. Initially confined to Asian countries, big Western pharmaceutical companies have recently started sifting through the orient’s vast indigenous knowledge for natural cancer remedies. </p>
<p><a href="http://www.cancerresearchuk.org/about-cancer/cancers-in-general/cancer-questions/what-is-kanglaite">Kanglaite</a> is an anti-tumour drug that was developed using modern technology. It contains extracts from coix seeds. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/25787906">Research</a> shows that Kanglaite has anti-cancer effects particularly in gastric, lung, and liver cancer. After passing the phase three clinical trials it was marketed along with conventional therapy to improve the patient’s quality of life.</p><img src="https://counter.theconversation.com/content/49598/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kareemah Gamieldien does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There are several natural remedies that have can help reduce cancer cells.Kareemah Gamieldien, PhD (Human Physiology), Cape Peninsula University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/499862015-11-03T04:06:11Z2015-11-03T04:06:11ZThe quest to find a drug that nails the tricky malaria parasite<figure><img src="https://images.theconversation.com/files/100525/original/image-20151102-16554-rjrqi5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A doctor observes mosquitoes to better understand the malaria parasite which has been developing a resistance to the anti-malarial drugs.</span> <span class="attribution"><span class="source">Reuters/RIcardo Rojas</span></span></figcaption></figure><p><em><em>This article is part of a series The Conversation Africa is running during malaria week in the Southern African Development Community. You can read the rest of the series <a href="https://theconversation.com/africa/topics/sadc-malaria-week">here</a>.</em></em></p>
<p>Malaria is a killer that has spent thousands of years adapting to the habits of its victim. Although the first confirmed case of human malaria dates to 450 AD, a millennia and a half later, the world is still battling the parasite that causes this disease. Today at least <a href="http://www.who.int/malaria/media/world_malaria_report_2014/en/">3.3 billion</a> people, or almost half of the world’s population, are at risk of contracting malaria. The heaviest burden is in Africa where an estimated 90% of malaria deaths occur.</p>
<p>To eliminate malaria and alleviate the disease scientists have to develop drugs that kill the parasite in the blood. But to prevent the spread of the disease in a community, these drugs also have to kill transmissible versions of the parasite that develop. </p>
<p>The challenge is that the world is running out of usable antimalarial <a href="http://www.who.int/malaria/media/world_malaria_report_2014/en/">drugs</a>. Antimalarial drugs that are widely used have a limited usable lifespan. This is because parasites develop resistance. The current drugs are becoming less effective as the parasite develops resistance against them. </p>
<p>To tackle this problem, researchers are investigating potential antimalarial drugs with multiple <a href="http://www.biomedcentral.com/content/pdf/s12936-015-0572-z.pdf">targets</a> to overwhelm the parasite and reduce resistance development. Multi-target drugs may also speed up the drug discovery and development process.</p>
<p>The multi-target inhibitors that we are <a href="http://www.biomedcentral.com/content/pdf/s12936-015-0572-z.pdf">studying</a> have been shown to target both the disease causing and transmissible forms.</p>
<h2>Understanding the malaria parasite</h2>
<p>The malaria parasite is an amazing shape shifter. It is able to change its shape in different environments to cause and spread the disease. In infected humans, the parasite lives within red blood cells leading to the symptoms and complications of the disease. The main symptoms include fever, headaches and vomiting which usually appear between 10 and 15 days after the mosquito <a href="http://www.who.int/topics/malaria/en/">bite</a>.</p>
<p>But when a female mosquito bites a human infected with malaria, a special form of the parasite, called a gametocyte, is drawn up from the person along with their blood. This special parasite then develops further in the newly infected mosquito and matures into another form of parasite that can be transferred to another human when the mosquito bites someone else. This leads to the spread of malaria. </p>
<p>With repeated exposure to a drug, the parasite cleverly adapts to the presence of the drug by changing its DNA. This means that the drug target in the parasite is no longer affected by the drug or that the parasite gets rid of the drug before it can reach its target. </p>
<p>To slow down the ability of the parasite to develop drug resistance, malaria medicine has been formulated into a combination therapy. It combines two antimalarial drugs that target different biological processes in a single tablet. It is considerably more difficult for the parasite to simultaneously change both targets in order to become resistant against both drugs. With combination therapies, the parasite has a significantly reduced chance of developing resistance compared to a single therapy. </p>
<p>Even though combination therapies have assisted in slowing down parasite drug resistance, the parasite is developing drug resistance to an antimalarial drug faster than new drugs are being developed and approved. </p>
<h2>A multi-pronged approach</h2>
<p>To increase and sustain the antimalarial armoury, drug developers need to deliver drugs faster and increase the lifespan of the drugs that are in circulation. </p>
<p>The answer to this conundrum may lie in the field of antibiotic drug discovery. </p>
<p>The antibiotic field is currently developing resistance-resistant <a href="http://www.cell.com/trends/pharmacological-sciences/abstract/S0165-6147(14)00172-2">antibiotics</a> that have multiple targets instead of single targets. Instead of a combination therapy that targets two single targets, a multi-target drug has numerous targets which the parasites need to develop resistance against. This makes it exponentially more effective than a combination therapy in resisting resistance. </p>
<p>One example of the outstanding success of this strategy is the TB drug, <a href="http://openres.ersjournals.com/content/1/1/00010-2015.full">SQ109</a>, which is currently in phase II clinical trials. It inhibits multiple targets with potent inhibition of TB cell growth and very low rates of spontaneous drug resistance. </p>
<p>A multi-target drug approach may provide the desired drug discovery breakthrough required to treat malaria. It would speed up the delivery of candidates into clinical practice and decrease drug resistance. </p>
<p>Ultimately, it would stop the spread of malaria by targeting the transmissible forms. In this way, we hope to stay one step ahead of the malaria parasite and make a dramatic difference to curb and eliminate the disease.</p><img src="https://counter.theconversation.com/content/49986/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bianca Verlinden receives funding from the SA National Research Foundation and SA Medical Research Council. </span></em></p><p class="fine-print"><em><span>Lyn-Marie Birkholtz receives research funding from the SA National Research Foundation and the SA Medical Research Council. </span></em></p>Across the world scientists are trying to find a new drug that the malaria carrying parasite will struggle to develop a resistance to.Bianca Verlinden, Postdoctoral Research Fellow, Molecular Parasitology, Department of Biochemistry, University of PretoriaLyn-Marie Birkholtz, Associate Professor (Biochemistry) DST/NRF South African Research Chair (SARChI) in Sustainable Malaria Control, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/490752015-10-28T04:30:40Z2015-10-28T04:30:40ZAfrica’s aquifers aren’t being protected as they should<figure><img src="https://images.theconversation.com/files/99330/original/image-20151022-5653-fjwagk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Despite the noble intentions behind charity wells, they may not be the best thing.</span> <span class="attribution"><span class="source">Franco Volpato/Shutterstock</span></span></figcaption></figure><p>NGOs often <a href="http://thewaterproject.org/digging-wells-in-africa-and-india-how-it-works">punt</a> the digging of wells as the solution to the long distances women in rural areas travel to collect water. These wells do improve the <a href="http://thewaterproject.org/health">quality of life</a>, but care needs to be taken in digging them as they could lead to the over-exploitation of aquifers. </p>
<p>It is true that wells have been advocated because they are easy to use, and because of the perception that groundwater is omnipresent. Also, the cost of sinking a well in comparison to other water supply infrastructure is <a href="http://www.kgs.ku.edu/Publications/PIC/pic23.html">minimal</a>.</p>
<p>But the <a href="http://www.iied.org/">International Institute for Environment and Development</a> has said that up to US$360 million has been spent on rural water supply schemes which are now <a href="http://pubs.iied.org/17055IIED.html">dysfunctional</a>. This equates to approximately 50,000 water points or pieces of infrastructure that have been installed and no longer <a href="https://rwsnblog.wordpress.com/2014/06/26/4-lessons-about-handpump-sustainability-in-ghana/">work</a>. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/99331/original/image-20151022-5653-16es577.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/99331/original/image-20151022-5653-16es577.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/99331/original/image-20151022-5653-16es577.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/99331/original/image-20151022-5653-16es577.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/99331/original/image-20151022-5653-16es577.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/99331/original/image-20151022-5653-16es577.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/99331/original/image-20151022-5653-16es577.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/99331/original/image-20151022-5653-16es577.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Research shows that large numbers of these well are left unused.</span>
<span class="attribution"><span class="source">Patrick Poendl/Shutterstock</span></span>
</figcaption>
</figure>
<p>In Bangladesh, for example, NGOs have pushed for wells to be dug. But recent <a href="http://news.nationalgeographic.com/news/2003/06/0605_030605_arsenicwater.html">research</a> suggests that human alteration to the landscape, the construction of ponds, and the adoption of irrigated agriculture are responsible for a pattern of increased arsenic concentration underground.</p>
<p>Added to this is the problem of unsustainable extraction. This takes place through a myriad of ways. The consequences can be devastating.</p>
<p>Sadly this is the only water people in the region have. They are forced to drink it and suffer from callouses on their hands and feet <a href="http://web.mit.edu/harvey-lab/Arsenic_in_Bangladesh.html">caused by</a> the arsenic.</p>
<p>A similar situation occurred in a small South African town a few years ago. Studies completed in the area noticed a decline in groundwater levels by as much as 25 metres over a period of 20 years due to unsustainable <a href="http://etd.uwc.ac.za/xmlui/handle/11394/2539">extraction</a>. The situation was so dire that calls were made for people passing through to transport water into the town. </p>
<h2>The Cinderella of water resources</h2>
<p>Aquifers across Africa are critical for potable water supply and help contribute as much as 70% of the total water supply in some <a href="http://apps.unep.org/publications/pmtdocuments/Groundwater_pollution_in_Africa.pdf">countries</a>. The management of these is critical.</p>
<p>For example, groundwater supplies the majority of small towns in South Africa, yet almost none of the municipalities employ a hydrogeologist on a full-time <a href="https://www.dwa.gov.za/Groundwater/Documents/GSDocument%20FINAL%202010_MedRes.pdf">basis</a>. This has led to the mismanagement of the subsurface water reserve and, in certain instances, the deterioration of groundwater quality and mining of aquifers.</p>
<p>A number of technical factors need to be taken into account on a site by site basis to make sure that groundwater is extracted sustainably.</p>
<p>It is a common misconception that when we drill, we tap into a river <a href="http://www.swissharmony.com/what-are-water-veins/">underground</a>. This is not the case. </p>
<p>Ground water moves slowly through, or is stored in, permeable rocks called aquifers. An aquifer may be a layer of almost any kind of gravel, sand or rock that has spaces between the pores able to hold moisture. The connectivity of these pores and the size of the pore, or cavity, will determine the ability to extract water from the subsurface. </p>
<p>There is a case to be made for and against using underground water. But monitoring is critical. The problem is that monitoring stations are regularly closed down and less data is available to manage the <a href="http://www.un-igrac.org/download/file/fid/288Yet">resource</a>.</p>
<p>The situation becomes critical when emergency supplies are needed and the groundwater reserves are able to replenish the already depleted surface water reserves. When the need arises, the automatic response is to pump groundwater to supplement surface water, but without the necessary management and monitoring systems in place.</p>
<h2>Working together for water</h2>
<p>A decentralised approach to managing the resource has been taken in certain African countries. For example, in West Africa, money is collected regularly from the users of a supply well in a village to help finance the maintenance of the well. </p>
<p>This approach doesn’t always work. The International Institute for Environment and Development has shown that nepotism is rife and the mismanagement of finances on such a small scale is <a href="http://www.undp.org/content/dam/undp/library/Democratic%20Governance/IP/Anticorruption%20Methods%20and%20Tools%20in%20Water%20Lo%20Res.pdf">common</a>.</p>
<p>In essence, a more co-ordinated effort is required which involves government, NGOs, academia and the private sector to sustainably develop and manage groundwater. This means that <a href="https://www.dwa.gov.za/groundwater/FAQ.aspx">licensing</a>, as exists in South African legislation, is needed prior to sinking a well or borehole for water supply or irrigation purposes.</p><img src="https://counter.theconversation.com/content/49075/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gaathier Mahed receives funding from CPUT. </span></em></p>The digging of wells in Africa has often been thought of as the solution to helping rural women walking to get water, but they may cause more harm than good.Gaathier Mahed, Hydrogeologist, Researcher and Senior Lecturer , Cape Peninsula University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/489492015-10-22T03:36:48Z2015-10-22T03:36:48ZUniversal health care is a tall order given southern Africa’s poor finances<figure><img src="https://images.theconversation.com/files/99165/original/image-20151021-15434-10xneeu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health care in Zambia is free but fraught with difficulties. </span> <span class="attribution"><span class="source">EPA/Kim Ludbrook</span></span></figcaption></figure><p>Creating universal health care – one of the targets under the newly ratified <a href="http://www.un.org/sustainabledevelopment/sustainable-development-goals/">Sustainable Development Goals</a> – will have different challenges for each country depending on their economic strength, relationships with donors, and their government’s investment into the health sector.</p>
<p>In southern Africa, the task will be even greater. To attain these healthcare goals, the region has more work to do than any other – especially considering its <a href="http://www.sadc.int/themes/poverty-eradication-policy-dialogue/">high poverty</a> levels and HIV and tuberculosis disease <a href="http://www.sadc.int/issues/hiv-aids/">burden</a>. The region is also still reliant on <a href="http://www.sadc.int/news-events/news/reduce-dependence-donor-funding-sadc-urged/">donors</a> despite efforts for governments to shoulder responsibility for health care.</p>
<p>Universal coverage, as defined in the goal, is access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines. It also includes protection from financial risk in terms of health care. The goal is that by 2030, all regions will have universal health care.</p>
<p>In southern Africa, South Africa and Zambia have taken the first steps towards universal health care. But both programmes are struggling to live up to expectations.</p>
<h2>A look at South Africa</h2>
<p>When South African Health Minister Aaron Motsoaledi introduced the <a href="http://www.bowman.co.za/FileBrowser/ContentDocuments/NHI.pdf">national health insurance (NHI) plan</a>, his idea was that it would bridge the healthcare <a href="http://www.gov.za/speeches/minister-aaron-motsoaledi-health-dept-budget-vote-201516-5-may-2015-0000">divide</a> between the wealthy and the impoverished. This is an inequality that stems from a legacy of poor health care for black and poorer people dating to apartheid. </p>
<p>The divided healthcare system in South Africa means that those who access public services often face severe delays, <a href="http://www.hst.org.za/publications/stock-outs-south-africa-national-crisis">stockouts</a> and inconsistencies in treatment. Public healthcare providers are often under-equipped and poorly staffed. The private sector, on the other hand, is supported by private health care insurance. Those who can afford it receive treatment by specialists, increased access to medicine and seldom experience delays in receiving services.</p>
<p>The NHI plan is intended to be implemented over 14 years. The first five years will see health facilities upgraded and health workers employed and trained.</p>
<p>If implemented correctly, the national health insurance scheme will:</p>
<ul>
<li><p>provide healthcare funding for all citizens based on a contributory system with wealthier people contributing more;</p></li>
<li><p>improve negotiations with providers such as hospitals, clinics and healthcare professionals to supply services and rational payment levels with quality assurance;</p></li>
<li><p>create one public fund with adequate reserves and funds for high-cost care; and</p></li>
<li><p>promote efficient and effective service delivery in both public and private sectors.</p></li>
</ul>
<p>But the plan has been described as <a href="http://mg.co.za/article/2013-05-03-00-let-private-skills-come-to-nhis-aid">unfeasible</a>. South Africa’s current healthcare system cannot support all-out-access to health care. There are several reasons why.</p>
<p>First, the health insurance proposal is a costly exercise. The government has yet to publish the funding model for the NHI, but one <a href="http://econex.co.za/publication/nhi-note-7/">estimate</a> published in 2010 pegged the cost of the insurance at US$16billion (R216 billion) per year. The estimate included existing government expenditure on health, which for 2015-16 is budgeted at <a href="http://www.treasury.gov.za/documents/national%20budget/2015/review/chapter%205.pdf">R157.3 billion</a>. </p>
<p>Some academics have estimated that increase by the proposed plan would need a 17% <a href="http://www.health-e.org.za/wp-content/uploads/2013/05/b443983d20a5b269befacd5f580f2d14.pdf">tax increase</a>, which is not feasible for the South African taxpayer.</p>
<p>Second, distribution of healthcare funds, a lack of trained healthcare professionals and increasing healthcare costs all detract from ministerial capacity to regulate public health care. The proposed plan is meant to address these concerns, but with the financial burden the plan will impose, it is currently unlikely that it will resolve these concerns.</p>
<p>However, the NHI plan could change how providers are paid, allowing everyone to access health care based on what patients need, not what they can afford. </p>
<h2>Health care for all in Zambia</h2>
<p>Universal access to health care in Zambia looks slightly different. Under the current administration, access to health services and medicine is free. In 2006, healthcare fees were dropped for patients in rural areas – the first step to provide free care for all Zambian citizens.</p>
<p>But the system has not been running smoothly. It has been plagued by medicine stockouts, a lack of trained healthcare professionals, uneven access to healthcare services in rural areas and a limited capacity from the ministry to maintain services.</p>
<p>Zambia’s health budget has <a href="http://www.reportlinker.com/p01083759-summary/Zambia-Pharmaceuticals-and-Healthcare-Report-Q1.html">increased</a> from USD1.42 billion (8.746 billion Kwacha) in 2014 to USD1.57 billion (9.983 billion Kwacha) in 2015. Despite this substantive allocation to <a href="http://info.worldbank.org/etools/docs/library/48612/zambia.pdf">health care</a>, there are still <a href="https://equinetafrica.org/bibl/docs/DIS29ngulube.pdf">budgetary</a> issues and irregular distribution of funds. </p>
<p>It was widely thought that user fees were the greatest reason for a lack of use of healthcare facilities. Dropping the fees resulted in a <a href="https://equinetafrica.org/bibl/docs/Dis57FINchitah.pdf">40% increase</a> in the use of healthcare services. But it failed to consider additional costs citizens would incur as they needed transport and access to clinics. This was unsustainable for them. </p>
<p>As a result of the increased costs related to transport, the poor in Zambia still struggle to access health care and medicines despite the premise of universal access to health care and medicines. </p>
<p>The challenges have also meant that the government has had extra costs in implementing the system. These are mainly transport costs because medicine stockouts require multiple trips back and forth and untrained staff mean trained staff need to travel to different hospitals in different regions.</p>
<p>Zambia cannot abandon its policy of free health care. Despite these challenges, however, the perception of universal access to health care in Zambia is still quite positive. The government is seen to be making increased efforts to address these challenges, including training staff, addressing supply chain management issues and managing funds allocated for health care.</p>
<h2>The regional health dilemma</h2>
<p>The challenges in Zambia and South Africa are faced in many unequal societies. In the developed world, universal health care is entirely different. Many Western systems rely on heavy taxation of their citizens to provide adequate universal access to health care. This cannot be a reality in southern Africa. Considering the high levels of poverty, most people cannot be taxed.</p>
<p>Universal health care would be positive for countries in the region, who all need access to health care and medicines. But the financial implications create barriers for this ideal. Many governments lack resources to provide health care for the impoverished. </p>
<p>That’s not to say it could never be achieved or that the ideal should not be worked towards. Increased collaboration with regional organisations, including the <a href="http://www.sadc.int/">Southern African Development Community</a> could assist in creating regional solutions for universal access to health care for the region. This would allow for stronger partnerships and increased funding to mitigate these challenges, and develop solutions to challenges faced by the Global South.</p><img src="https://counter.theconversation.com/content/48949/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erica Penfold receives funding from the Economic Science and Research Council. She is affiliated with The South African Institute of International Affairs. </span></em></p>Healthcare that everyone can access is an important step in bridging the inequality in a country. In reality though, its hard to implement properly.Erica Penfold, Research Fellow, South African Institute of International AffairsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/456042015-08-13T04:57:54Z2015-08-13T04:57:54ZA polio-free world is in sight: what’s needed to wipe out the last 1%<figure><img src="https://images.theconversation.com/files/91453/original/image-20150811-11068-1igsocv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Afghanistan and Pakistan are the only two countries that still have endemic levels of polio.</span> <span class="attribution"><span class="source">Parwiz/Reuters</span></span></figcaption></figure><p>The next three years are crucial in the global fight to eradicate the last 1% of polio cases and contain the virus across the world. But it will only become a reality with a combination of intensive vaccination campaigns and high-level surveillance to trace and monitor each polio case and circulating viruses. </p>
<p>Central to achieving this is the polio eradication and endgame strategic plan 2013 to 2018. The plan belongs to World Health Assembly’s Global Polio Eradication Initiative. It was developed to eliminate and contain all wild, vaccine-related and <a href="http://www.polioeradication.org/Polioandprevention/Thevaccines/Oralpoliovaccine(OPV).aspx">sabin</a>, which is a live but weakened strain, of the polioviruses by 2018. </p>
<p>Since the <a href="http://www.who.int/mediacentre/news/releases/2010/polio_eradication_20100616/en/">initiative</a> was launched by the assembly in 1988, the number of polio cases have reduced by 99%. The remaining 1% of cases can be found in the two countries with endemic polio – Pakistan and Afghanistan. Nigeria was the third polio-endemic country until July 2015, when it recorded one full year with no new cases.</p>
<p>Polioviruses belong to the family of viruses that infect the human gastrointestinal tract and cause diseases of the nervous system. It is caused by one of three related wild polioviruses: poliovirus types 1, 2 and 3 or as a result of a poliovirus derived from a <a href="http://www.who.int/features/qa/64/en/">vaccine</a>. </p>
<p>The vaccine-derived poliovirus develops when the weakened vaccine-virus given to a child during immunisation is excreted in areas with bad sanitation. It then circulates.</p>
<p>Although wild poliovirus type 2 was eradicated worldwide in 1999, the majority of reported cases are from vaccine-derived poliovirus outbreaks associated with type 2 wild poliovirus. </p>
<h2>Challenges in the plan</h2>
<p>Eliminating this last 1% of polio cases requires two main strategies in the plan: immunisation and surveillance. Its immunisation arm aims to achieve a high level of immunity across all populations while the surveillance arm picks up new cases. </p>
<p>To achieve the two elements, a combination of innovations may be required. The innovations need to be applied in the most challenging conditions and should be tailored for each country and its settings.</p>
<p>Currently, <a href="http://www.polioeradication.org/Polioandprevention/Historyofpolio.aspx">2.5 billion children</a> across the world have received vaccination against polio.</p>
<p>The challenges holding back immunisation include:</p>
<ul>
<li><p>political unrest;</p></li>
<li><p>dealing with misinformation that the polio vaccine causes sterility and/or AIDS;</p></li>
<li><p>the banning of healthcare workers from vaccinating certain communities; or</p></li>
<li><p>attacks on healthcare workers distributing vaccine, as has been the case in Nigeria and Pakistan.</p></li>
</ul>
<p>In 2003, the polio vaccination was stopped in parts of northern Nigeria. This caused a polio outbreak in six other countries. In Pakistan, the Taliban have launched several attacks on healthcare workers trying to vaccinate children. </p>
<p>Today, problems still persist in Pakistan. And recently, a church in Kenya started a misinformation <a href="http://www.christiantoday.com/article/boycott.polio.vaccine.say.kenyas.catholic.bishops/60587.htm">campaign</a>.</p>
<h2>Why surveillance is important</h2>
<p>Polioviruses replicate in the intestine of infected people and are shed in high numbers in faeces. As a result, the virus is found in sewage and faecally contaminated water sources. Active surveillance is important to identify residual pockets of the poliovirus. These inform the areas where the supplementary immunisation campaigns are required. </p>
<p>Most people infected with polioviruses have inapparent or mild disease but a small percentage will develop polio. To successfully eliminate the disease, it is important that experts monitor both the virus’ transmission and the characteristics of people who have contracted the disease. </p>
<p>There are two aspects of surveillance. Within the global initiative, the gold standard for surveillance is the monitoring of cases of <a href="http://medical-dictionary.thefreedictionary.com/Acute+flaccid+paralysis">acute flaccid paralysis</a>, or weakness in the limbs, in children under 15. Once this is picked up, further investigation needs to be done in the immediate community. </p>
<p>But in regions where the surveillance for the acute flaccid paralysis is either low or absent, alternate surveillance is needed. Here, environmental surveillance must be applied at sites where the virus is suspected to persistently circulate or can be reintroduced. This entails monitoring the sewage in high-density urban populations.</p>
<p>The benefit of this strategy was seen in 2013 when wild poliovirus was detected in the sewage in southern and central Israel and the West Bank. No cases of polio were reported but the poliovirus found was related to viruses present in Egypt and Pakistan. This early warning prompted an additional immunisation programme to prevent a potential outbreak of polio. </p>
<h2>Towards the end goal</h2>
<p>Until 2018, there will be continuous environmental surveillance of the poliovirus in polio-endemic areas of Pakistan, Afghanistan and the recently cleared Nigeria. Virologists will try to identify residual transmission and new importations. They will also monitor the switch from the vaccine that treats all three wild polioviruses to the one which treats only two. The third has been eradicated.</p>
<p>This strategy provides an important passive and non-invasive supplementary surveillance system to monitor circulating polioviruses in non-endemic countries and countries still using oral polio vaccines. This was shown in Israel.</p>
<p>Eliminating polio worldwide is achievable. But the success or failure of the global initiative depends on political and social will and adequate funding. </p>
<p>Since 1988, more than <a href="http://www.polioeradication.org/Polioandprevention/Historyofpolio.aspx">US$9 billion</a> has been invested into the global polio eradication initiative. Although more money is needed for the plan to be implemented until 2018, donor fatigue and anti-vaccine movements, such as those in Nigeria and Pakistan, could derail the process. This could cause a public health crisis. </p>
<p>But with adequate immunisation and the surveillance of both acute flaccid paralysis and the environmental factors, the polio-free status of the non-endemic countries can be maintained. This will also ensure that the transmission of polio in endemic countries is identified and interrupted.</p><img src="https://counter.theconversation.com/content/45604/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maureen Taylor receives funding from water utilities (Rand Water, Midvaal Water, Sedibeng Water), the National Research Foundation, Water Research Commission and the Poliomyelitis Reseatch Foundation.</span></em></p>Eradicating the last 1% of polio cases in the world requires an endgame plan centred on immunisation and surveillance.Maureen Taylor, Professor of Virology , University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/456882015-08-11T04:19:26Z2015-08-11T04:19:26ZThe legacy benefits from Africa’s fight against polio<figure><img src="https://images.theconversation.com/files/91166/original/image-20150807-27582-dhcw9j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Nigerian commissioner for health of Bauchi state, Sani Malam, administers a polio vaccine to a child during an immunisation drive.</span> <span class="attribution"><span class="source">EPA/Deji Yake</span></span></figcaption></figure><p>The campaign to eradicate polio in Africa has had a number of positive spinoffs for the health sector on the continent. Chief among these have been community involvement, multi-disciplinary partnerships, improved health care and the strengthening of health systems. </p>
<p>For decades, polio took a heavy toll on both children and adults. Before the development of two polio vaccines in the 1950s and the 1960s, about half a million people a year were <a href="http://www.who.int/mediacentre/factsheets/fs114/en/">paralysed</a> or died. Today, more than 10 million people who would otherwise have been paralysed by <a href="http://www.who.int/mediacentre/factsheets/fs114/en/">the virus</a> are able to walk because of these vaccines. </p>
<p>Globally, more than <a href="http://www.polioeradication.org/portals/0/document/resources/strategywork/economiccase.pdf">US$9 billion</a> has been ploughed into polio eradication since the the 1980s. This has resulted in more than <a href="http://www.polioeradication.org/Polioandprevention/Historyofpolio.aspx">2.5 billion</a> children being immunised against polio. The Global Polio Eradication Initiative estimates that it has already generated benefits worth $27 billion through its vaccination campaigns and the deaths it averts. The administration of vitamin A during these campaigns has also helped. </p>
<p>But in addition to the humanitarian and financial benefits, anti-polio campaigns have also had a positive impact on health services and the development of health infrastructure. </p>
<h2>A more involved community</h2>
<p>The greatest positive impact has been in community mobilisation and multi-disciplinary partnerships. These are inseparable pillars of primary health care and two strategies that have proved the most difficult to implement. </p>
<p>Within community mobilisation, the main elements are strengthening existing community organisations, using educational campaigns and advocating the involvement of political and <a href="http://www.unicef.org/immunization/polio/index_49028.html">community leaders</a>. Through the polio eradication campaigns, these approaches have been successfully adopted by other health programmes. </p>
<p>Involving the community ensures two things. First, people are motivated to bring their children to be vaccinated during mass campaigns. They also continue to bring their children for routine vaccination visits after the campaigns. </p>
<p>Second, these communities become actively involved in the campaigns. They often help deliver vaccines, maintain the vaccine cold chain and avail their own resources to campaigns, forming an active part of the vaccine supply chain. </p>
<p>In Nigeria, for example, community members donated money, used their vehicles, volunteered their time and availed personal resources for these operations. On occasion, this cost them their own lives. Many vaccinators in Nigeria were <a href="http://europe.newsweek.com/polio-related-murders-kill-more-disease-itself-287880">killed</a> in targeted assassinations. </p>
<p>A good proportion of vaccine storage equipment used in immunisation programmes across Africa, such as cold stores, freezers and refrigerators as well as transporting equipment such as coolers, vaccine carriers and ice packs, were procured in the polio eradication initiative. </p>
<h2>Improved health care services</h2>
<p>Polio eradication has helped raise the profile of the public health sector. It has done this by creating a renewed demand for vaccination services, resulting in higher routine vaccine coverage. </p>
<p>But the model has also shown innovative ways to deliver health services. For example, to increase the coverage of vaccine in security-affected states in Nigeria, federal and state governments developed a specific <a href="https://www.rotary.org/myrotary/en/polio-vaccinators-make-significant-headway-nigeria">strategy</a> in those parts of the country. Known as “hit and run”, local vaccinators would move into a rural area in the morning, vaccinate children speedily and leave as soon as possible.</p>
<p>Some health programmes have taken on features developed for the polio eradication initiative, such as:</p>
<ul>
<li><p>setting up partnerships between agencies, disciplines and sectors;</p></li>
<li><p>engaging the media and improving communication systems to reach entire populations;</p></li>
<li><p>increasing community involvement;</p></li>
<li><p>creating innovative knowledge management systems;</p></li>
<li><p>improving programme management capacity; and</p></li>
<li><p>establishing high-quality disease surveillance. </p></li>
</ul>
<p>It has also helped to pinpoint gaps and weaknesses in health service delivery and in many cases helped to fill these gaps. This includes strengthening the <a href="http://www.unicef.org/immunization/polio/index_49025.html">supply chain</a> processes.</p>
<p>And like the campaign to eliminate smallpox, the global polio campaign also brought health services to under-serviced populations, such as children trapped in war zones. In the lead-up to the Muslim religious holiday Eid earlier this year, a <a href="http://www.polioeradication.org/mediaroom/newsstories/Children-Reached-with-Polio-Vaccines-in%20Yemen/tabid/526/news/1259/Default.aspx#sthash.AI43xqQl.dpuf">humanitarian pause</a> allowed 50,000 children to receive polio vaccines in Yemen.</p>
<h2>Towards a polio-free world</h2>
<p>Important lessons were also learnt at the international level. The World Health Organisation has successfully brought together an unprecedented <a href="http://www.polioeradication.org/AboutUs.aspx">global team</a>. It includes governments, other UN agencies, non-governmental organisations, community groups, the business community and religious organisations. </p>
<p>A new strategic plan has been <a href="http://www.polioeradication.org/Resourcelibrary/Strategyandwork.aspx">developed</a> to ensure successful worldwide eradication of polio by 2018. The plan was created along with polio-affected countries, donors and national and international advisory bodies. It is the first plan designed to eradicate all types of the polio disease from wild poliovirus to vaccine derived polioviruses.</p>
<p>Once polio is eradicated, the world can celebrate the delivery of a major global public good benefiting all equally. But most importantly, success will mean that no child will ever again endure the misery of lifelong <a href="http://www.polioeradication.org/Polioandprevention/Historyofpolio.aspx">polio paralysis</a>.</p><img src="https://counter.theconversation.com/content/45688/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charles Shey Wiysonge does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The positive impact of the polio eradication initiatives on the continent can be felt across the health sector in other health programmes.Charles Shey Wiysonge, Professor of Clinical Epidemiology at the Faculty of Medicine and Health Sciences, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/449322015-08-07T04:40:34Z2015-08-07T04:40:34ZWhy Nigeria took so long to get non-polio endemic status<figure><img src="https://images.theconversation.com/files/91012/original/image-20150806-5233-1utpree.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A health worker vaccinates children with drops of polio vaccine in a classroom in Lagos, Nigeria. </span> <span class="attribution"><span class="source">Reuters/George Esiri</span></span></figcaption></figure><p>For both Nigeria and the continent, the country’s removal from the list of polio endemic countries is a huge step towards Africa complying with the global goal of becoming polio free by <a href="http://www.polioeradication.org/Portals/0/Document/Resources/StrategyWork/PEESP_CH0_EN_US.pdf">2017</a>. The goal is part of the World Health Assembly’s Global Polio Eradication Initiative, to deliver a polio-free world in the next three years.</p>
<p>Until now, Nigeria was one of only three countries in the world on the ignoble list of polio endemic countries. The other two were Pakistan and Afghanistan. The list contains the countries that have never interrupted the transmission of polio. To be removed from the list you must have no polio for at least one year. And to be declared polio free, the World Health Organisation needs to certify that the country has had no new cases of the wild poliovirus reported for three successive years. If Nigeria continues its current trend, it could be declared polio free by 2017. </p>
<p>But considering the resources that have been pumped into polio eradication in Nigeria and the detailed prevention strategy in place in the country, Nigeria could have been declared polio free 10 years ago.</p>
<p>Nigeria’s move off the list of polio endemic countries leads us to three questions: Firstly, why did it take Nigeria so long to get to this stage? Secondly, what led to Nigeria’s sudden achievement? And third and most importantly, what must Nigeria continue to do to ensure that the country is finally free of polio?</p>
<h2>The challenges around polio</h2>
<p>In 2008, Nigeria alone accounted for <a href="http://www.who.int/csr/don/2008_06_18/en/">86%</a> of all the polio cases on the continent. The other cases came from Niger, Congo, Senegal, Angola and Chad.</p>
<p>There are two reasons the country was the epicentre of the virus at the time. One relates to immunisation. The country’s national <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5926a2.htm">immunisation programme</a> performed sub-optimally. There was an abysmally low number of routine immunisations during this period.</p>
<p>But the main stimulus for a high number of polio cases came in 2003. It was a call by a front line medical practitioner and a prominent member of the Supreme Council for Sharia in Nigeria to boycott anti-polio vaccinations in the country’s <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4098042/">northern states</a>. The call followed fears that the polio vaccine had been contaminated with <a href="http://edition.cnn.com/2003/WORLD/africa/10/27/nigeria.polio.reut/">anti-fertility steroids</a>. </p>
<p>The resulting boycott brought the wobbly national polio eradication programme to a total collapse. As a result, the average annual reported polio cases shot up from 400 between 1998 and 2002 to 750 cases after the 2003 call. By 2006, there were over <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4098042/">1100 new cases</a> of polio that year.</p>
<p>Frantic national and international efforts were made to end the boycott. This included a resolution being adopted at the 61st World Health Assembly in <a href="http://www.who.int/mediacentre/events/2008/wha61/journal5/en/">2008</a> calling on Nigeria to reduce the risk of international spread of poliovirus by ensuring that all children in the north of the country were vaccinated against polio. The special and negative mention Nigeria received at the global level appeared to have <a href="http://www.polioeradication.org/content/polionews/polionews31.pdf">moved the country</a> in the right direction for achieving polio eradication.</p>
<h2>What Nigeria did right</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=411&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=411&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=411&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=517&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=517&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90885/original/image-20150805-22478-yc209g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=517&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Volunteer Health officials wait to immunise children at a school in Nigeria’s capital in 2010.</span>
<span class="attribution"><span class="source">REUTERS/Afolabi Sotunde</span></span>
</figcaption>
</figure>
<p>The polio eradication strategy was twofold. Firstly, traditional and community leaders, civil society organisations and women groups were brought into the polio eradication activities to encourage the community to <a href="http://www.polioeradication.org/mediaroom/newsstories/Partnering-with-religious-schools-to-fight-against-polio-in-Nigeria/tabid/526/news/774/Default.aspx">“own”</a> the initiative.</p>
<p>Secondly, emergency operations centres were established in Abuja and six Northern states. Through these centres real-time and detailed information was gathered about the eradication programme in key endemic states. This meant any new polio cases were rapidly detected and the appropriate approach could be co-ordinated in these states. </p>
<p>The system was further enhanced with an accountability framework for team members and groups involved. Individuals, and not just the system or organisation, were held responsible and accountable for their performance.</p>
<p>The system proved so successful that they were deployed and used to control the 2014 <a href="https://theconversation.com/how-nigeria-beat-the-ebola-virus-in-three-months-41372">ebola outbreak</a> in Nigeria.</p>
<h2>The road to become polio-free</h2>
<p>Nigeria still has some distance to go to polio free status. It must be continuously stressed that the end of polio is only in sight and at the end of a two year tunnel. On two previous occasions - in 2007 and 2011 - Nigeria shifted focus from polio eradication to electioneering <a href="http://www.polioeradication.org/mediaroom/newsstories/Maintaining-Momentum-in-Nigeria-is-Crucial-for-a-Polio-free-Africa/tabid/526/news/1205/Default.aspx">campaigns</a>. As a result, polio resurged. </p>
<p>For the country to achieve a polio free status, it requires two things: a sustained political commitment to polio eradication and a massive operation with adequate funding and meticulous co-ordination. Nigeria’s progress against polio over the last few years has been a combination of this grand coordination and attention to small-scale detail. </p>
<p>All levels of government need to implement routine immunisation. Insecurity in the northeast part of the country has left many settlements in the area inaccessible to health workers. Access to these areas will be critical. </p>
<p>Nigeria cannot afford to be complacent. The current government must build on the achievement of the past government and sustain political commitment to eradicating not only polio and controlling other infectious diseases that still plague the country. Adequate funding must be provided to sustain and expand the operations of emergency operations centres to every state, with adequate funding and management by qualified staff.</p>
<p>Had Nigeria done what was right regarding the polio eradication initiative and routine immunisation, none of these Nigerians would have been maimed, incapacitated and paralysed forever by polio. This is the poignant message for the world, of Nigeria’s current non-polio endemic status, and a reason to ensure polio free status by 2017 and forever.</p><img src="https://counter.theconversation.com/content/44932/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Oyewale Tomori does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nigeria’s strategy to eliminate polio was so effective that it was duplicated to deal with ebola. So why did the country take so long to get off the list of polio-endemic countries?Oyewale Tomori, President , Nigerian Academy of ScienceLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/447862015-08-05T04:48:45Z2015-08-05T04:48:45ZAfrica is within reach of being declared a polio free region<figure><img src="https://images.theconversation.com/files/90746/original/image-20150804-11977-1wq5rxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Senegalese Mamou Tiang, who suffers from polio, begs for money outside a bank on a sidewalk in the capital Dakar. </span> <span class="attribution"><span class="source">Nic Bothma/EPA</span></span></figcaption></figure><p>More than 20 years after North and South America eliminated the threat of polio, sub-Saharan Africa is finally on the brink of being declared polio-free. Last month the region marked <a href="http://www.polioeradication.org/">one year</a> without a new polio case following the last case in Nigeria on 24 July 2014. If no new cases are reported for another three years, Africa will be certified polio-free by late <a href="http://www.unicef.org/immunization/polio/">2018</a>. </p>
<p>Polio has maimed and killed hundreds of thousands of people across the globe. Polio paralysis has caused physical suffering, life-long dependency, loss of productivity and placed a heavy burden on poor families.</p>
<p>As a result of the use of two vaccines developed more than 50 years ago the annual number of polio cases has globally dropped by more than <a href="http://www.who.int/mediacentre/factsheets/fs114/en/">99%</a> from about half a million in the 1980s to only 34 so far in 2015. But eliminating the last 1% of cases of polio is still proving to be a challenge. </p>
<p>Currently, only parts of two countries in the world remain polio-endemic – <a href="http://www.polioeradication.org/Infectedcountries.aspx">Pakistan and Afghanistan</a>. </p>
<h2>The workings of the poliovirus</h2>
<p>Polio is a communicable disease caused by one of three related wild polioviruses: poliovirus types 1, 2 and 3. It attacks at any age but mainly affects children under five. The virus typically enters the body through the mouth and multiplies inside the gut. Initially it manifests as flu-like symptoms. Once established, it enters the bloodstream and attacks the central nervous system. As it proliferates, it destroys nerve cells which stimulate muscles. These nerve cells cannot be renewed and affected muscles no longer function. The virus circulates silently at first, possibly infecting up to 200 people before the first case of paralysis surfaces. </p>
<p>Immunity against polio comes from either natural infection, which is when one recovers from polio or is immuned against contracting the disease through vaccination. There are two polio vaccines which are highly effective. The first is an injectable vaccine developed in the 1950s, the second an oral vaccine developed in the 1960s. </p>
<p>Of the three poliovirus types, type 2 was successfully eradicated in 1999 and worldwide cases of the other types are down to the lowest levels ever.</p>
<h2>The plan to eradicate polio</h2>
<p>In <a href="http://www.who.int/ihr/polioresolution4128en.pdf">1988</a> the World Health Assembly, which governs the World Health Organisation, adopted the Global Polio Eradication <a href="http://www.who.int/mediacentre/news/releases/2010/polio_eradication_20100616/en/">Initiative</a>. </p>
<p>The strategy was developed as a result of the success in eradicating smallpox in the 1970s, because of the similarities in the spread of the viruses. Like smallpox, polio only attacks humans. Polio viruses also only survive for a very short time in the environment and there are no animal or insect reservoirs that carry them. Similar to smallpox, polio can be eradicated and an effective vaccine is available. Once a person is immunised against it, immunity is life-long. </p>
<p>The polio strategy included widespread routine vaccinations, mass vaccination campaigns and a rapid response to polio cases. But the most critical element of the strategy is surveillance - in the community and the laboratory - to find polio cases that may have been ignored or initially overlooked.</p>
<p>Surveillance in the community needs to involve both the general public and health care workers. Health care workers need to report all cases where children experience abrupt weakness in the limbs, even if the weakness is presumed to be triggered by an injection. Community leaders need to report any newly paralysed children in their communities to health care services.</p>
<p>In the laboratory, the specific polio virus is identified and its source determined. Without this high-quality surveillance it would be difficult to locate where and exactly how the poliovirus is circulating or to confirm when its transmission has been stopped. </p>
<h2>Making Africa a polio-free region</h2>
<p>Countries are certified to have eradicated polio only if no cases of the wild poliovirus are reported for three successive years. There must be documented evidence from high-quality surveillance which shows this. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=408&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=408&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=408&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=513&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=513&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90747/original/image-20150804-11971-lorn0j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=513&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A child receives an oral polio vaccination.</span>
<span class="attribution"><span class="source">epa.eu</span></span>
</figcaption>
</figure>
<p>Currently, four fifths of the world’s population live in regions certified to be polio-free. In 1994, the Americas were certified polio-free, followed by the Western Pacific region in 2000. Europe received its certification in June 2002 and the South-East Asian region in March 2014. </p>
<p>In 1996 African heads of state resolved to stamp polio out of Africa. Then South African President <a href="http://www.mandela.gov.za/mandela_speeches/1996/960802_polio.htm">Nelson Mandela</a> launched the three-year “Kick Polio out of Africa” campaign. But by <a href="http://www.unicef.org/immunization/files/The_Story_of_the_End_of_Polio.pdf">2000</a>, wild poliovirus was still circulating in Egypt, Niger, and Nigeria. The situation worsened when the polio vaccination was stopped in <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001405">northern Nigeria</a> for religious reasons. As a result, polio transmission spread from the area to eight other African countries in 2003. </p>
<p>Poliovirus continued to circulate in Africa until last year. But the number of affected countries has steadily been decreasing. In 2004 there were 14 countries that had polio outbreaks. These included Benin, Botswana, Burkina Faso, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Egypt, Ethiopia, Guinea, Mali, Niger, Nigeria, and Sudan. In 2011, this dropped to 12. Last year, there were only five African countries with polio outbreaks: Nigeria, Cameroon, Equatorial Guinea, Ethiopia, and Somalia. </p>
<p>In all these outbreaks, the common factor was the country’s failure to immunise. The reasons for this failure varied from one outbreak to another, but in each case there was a group of non-vaccinated people that enabled the poliovirus to seed itself and spread far and wide. </p>
<p>The size of the unimmunised population ranged from small isolated groups which refused vaccination for religious or <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001405">cultural reasons</a> to entire birth cohorts in areas like Somalia experiencing <a href="http://www.emro.who.int/polio/polio-news/wild-poliovirus-somalia-may-2013.html">humanitarian emergencies</a>. </p>
<h2>The endgame around polio</h2>
<p>As long as a single child remains infected, children in all countries are at risk of contracting polio. </p>
<p>While the humanitarian benefits of polio eradication in Africa will be immeasurable, efforts have been made to quantify the financial savings that can be anticipated. </p>
<p>The World Health Organisation estimates that once polio is eradicated and vaccination halted, global savings from vaccination, treatment costs, and rehabilitation will amount to nearly <a href="http://www.ncbi.nlm.nih.gov/books/NBK11763/">US$2 billion</a> a year. </p>
<p>African countries should start careful polio legacy planning now to ensure that most of that money is redirected to other health programmes.</p><img src="https://counter.theconversation.com/content/44786/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charles Shey Wiysonge does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It’s been one year since the last polio case was reported in Africa. If the continent keeps this up, it could be declared polio free by 2018.Charles Shey Wiysonge, Professor of Clinical Epidemiology at the Faculty of Medicine and Health Sciences, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.