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AFRO-NETS> A boost for Safe Health Care in Africa

A boost for Safe Health Care in Africa
Dear Colleagues,
The issue of Safe Healthcare recently received a tremendous boost 
when a second Senate Congressional Hearing was held and this one has 
proved considerably more successful than the first. It is estimated 
that US$ 100 million dollars a year is enough to provide the whole of 
Africa with auto-disable syringes. A mere drop compared to US$ 15 
billion. If all the rumors prove true, then funding to deal with this 
very important but much neglected area could soon be forthcoming as 
part of the Bush Global AIDS Bill.
I recently had the privilege and honour of testifying before the Sen-
ate Congressional Hearing on the issue of Safe Healthcare in Africa 
and HIV/AIDS on July 31st 2003. This was the second hearing on the 
subject but unlike the first one I am pleased to say the question has 
now moved from argument and controversy about what proportion or per-
cent of HIV is spread by unsafe healthcare to quite properly, concern 
about making the safest healthcare available in Africa.
The five panellists were: Dr. Anne Peterson (USAID) and Dr. Yvan 
Hutin (WHO/SIGN), Dr. John Kiwanuka Ssemakula (Medilinks), Holly 
Burkhalter (Physicians for Human Rights), and John Stover (The Fu-
tures Group International).
I?d just come back from a trip to Uganda where I visited a number of 
health clinics and talked with and interviewed health workers, nurses 
and Doctors who are on the frontlines of fighting AIDS, for their 
views on the issue of unsafe health care and the dangers of spreading 
HIV/AIDS associated with this. I used part of what they told me at 
these meeting as part of my testimony at the Senate Hearing and it 
helped in passing along a very powerful message to the Senators just 
as I promised them I would.
The hearing went very well indeed, here is an extract of what people 
who were there said: "At one point, Sen. Jeff Sessions (R-AL), who 
chaired the hearing, asked something along the lines of whether we 
can get AD syringes all over Africa in 6 months -- he wants to get 
something done soon! Sessions has been talking with the key Admini-
stration figures on this (Director of the Office of National AIDS 
Policy Joe O'Neill was at the hearing) -- I think he said he even 
talked to Bush -- and seems keen on getting a portion of the money in 
the AIDS bill to go towards injection safety and blood safety (and 
maybe gloves, etc., though focus of the hearing was injection safety 
and blood safety -- though Holly made some important remarks about 
universal precautions)."
My full oral testimony is provided below - the testimony of other 
panelists can be accessed at:
My written testimony is available for download at:
Senate Hearing Committee on Unsafe Health Care and the HIV/AIDS epi-
demic in Africa 
Oral Testimony of Dr. John Kiwanuka Ssemakula (MD, MPH) 
Washington DC, USA, 31st July 2003 
Senators, thank you for affording me the honor and privilege to ad-
dress this Senate Hearing Committee on the very important subject of 
"Safe Health Care in Africa". My name is John Kiwanuka Ssemakula a 
Ugandan Doctor currently working as a Public Health Consultant with 
the Africa-America Institute. I trained as a Doctor at Ibadan Univer-
sity, Nigeria, and Makerere University, Uganda. I also run a website 
called Medilinks which publishes health related information for Af-
rica including that of HIV/AIDS.
I have had a professional and personal relationship with HIV/AIDS 
throughout my tertiary education, both in medical school, and then my 
on-the-ground experiences as a young physician first undertaking a 
medical internship, and as a medical officer in the early 1990?s, 
during the peak period of the HIV/AIDS crisis in Uganda.
My interest in HIV/AIDS is not just professional, it is also on an 
intensely personal level. I have lost several cousins, who were like 
brothers and sisters to me over the years. One was a doctor, another 
was an engineer doing a Masters, others were in university. I have 
also lost aunts and uncles who left behind orphaned children that we 
have helped educate and bring up over the last 15 years.
I have been following the issue of unsafe healthcare and its role in 
the spread of HIV/AIDS in Africa, for a year, from the time re-
searcher David Gisselquist sent me a draft of his ground-breaking pa-
per almost a year ago and the controversy that ensued when it was 
published in the International Journal of STDS & AIDS.
As far as I was concerned people who were discussing the issue in 
terms of controversy were missing the point completely, for there was 
no controversy. It was not about the percent of HIV/AIDS that was 
transmitted via the unsafe use of needles, be it 2.5%, 10% or even 
40%. It was simply about safe health care, the first and most basic 
thing a health worker should provide. I have since learnt that rela-
tively cheap technologies such as auto-disable syringes made by BD or 
Star and even retractable syringes that could help deal with the 
problem already exist.
I?ve just come back from Uganda where I?ve been talking to people 
about the issue of unsafe health and the possibility of getting AIDS 
through needles?. None of the people I talked to saw any controversy. 
No one jumped to the conclusion that providing safe health care would 
lead to more unsafe sex. People had equal concerns about safe health 
care and safe sex, saying we need both.
While in Uganda I also attended the Uganda Bishops Council, where 
they were taking landmark decisions on Adolescent Youth Sexual and 
Reproductive Health. They were very excited to hear that I could be 
testifying before the Senate. All agreed that the issue of re-use of 
needles was very important. "We are sending you as our emissary to 
USA and we are trusting you to tell the Senators about us. Tell the 
Senators, we are also working very hard. We appreciate any and all 
help you can give us in our fight against HIV/AIDS."
I also visited Health centres in Uganda, first in Rakai district 
where AIDS was first seen in Uganda and then in Luwero district. Sis-
ter Namperwa of Kakuto Health Centre in Rakai District said to me, 
"If you have these auto-disable syringes and you can bring them to 
Uganda it will be good. It will help Doctors at those clinics further 
up-country, they are just stuck, and are worn out dealing with AIDS 
everyday. This is a problem they have no means to deal with!"
While at Luwero Health Centre I asked Sister Margaret Serunjoji, the 
In-Charge of the Maternity wing if there was a problem with the re-
use of needles. She said in immunization there was no problem, except 
when they were running low on supplies. But she said they had nothing 
similar for curative services. When I told her about the existence of 
auto-disable syringes and the moves to make them available in Africa, 
she became excited.
Sr. Serunjoji said "This is just what we need. Even though we do not 
re-use needles here because the supply is generally good, sometimes 
we run out. When that happens patients are forced to buy syringes. 
But the problem is even at 300 Shs (15 cents) it is still too expen-
sive for most villagers. So when a patient comes with their own sy-
ringe they will tell the doctor to give them their needle so they can 
go back and boil it and re-use it. They do not want to buy a syringe 
every time because it cost too much."
I remarked "Isn?t it particularly dangerous especially with the dan-
ger of HIV/AIDS in Uganda, isn?t there the possibility of it being 
spread this way?"
Dr. Ssekabira replied, "This is a very real problem. It is even more 
urgent if one realizes that when the patient buys a needle sometimes 
they share one needle among their family, using it over and over 
again or may even share with their neighbours. Auto-disable syringes 
that were cheap enough and supplied in enough quantities would pre-
vent this. This is not just an issue of health, but also of poverty."
All the doctors and nurses I met in the past few weeks were concerned 
about HIV transmission in health care settings. Because health care 
workers today are still living many of the same experiences that I 
lived through as a practicing doctor in Uganda.
As a medical student and a Junior House Officer in Mulago hospital in 
Kampala in the late 80?s and 90?s I witnessed the re-use of needles 
constantly. Sometimes the needles were so blunt they would actually 
cause trauma to the patient and blood would flow. Many colleagues re-
call similar stories.
So concerned were we as junior Doctors doing most of the work and in 
the frontline, we went on a work to rule demanding equipment such as 
disposable needles and gloves that would allow us to do our jobs in a 
safe environment, both for the protection of ourselves and our pa-
tients. I remember one time a colleague and I decided to do an infor-
mal survey of the rate of HIV on our patients. We were shocked to 
discover that up to 50% of our patients were HIV+ve.
While at Mulago working in the Paediatrics Department, I and col-
league Dr Madewo noticed, we were seeing children presenting as 
HIV+ve when the mother was not. Some of the children were quite old. 
We thought perhaps they were being infected through immunisations or 
somehow by either injections or unsafe blood. Unfortunately for vari-
ous reasons we were unable to investigate further. I believe this was 
a missed opportunity to investigate the possibility of HIV being 
spread in a medical setting.
There is no denying that unsafe sex is probably the major route for 
transmission of AIDS, but other routes such as re-use of needles and 
other unsafe healthcare practices are just as significant. The mes-
sage of safe sex and behavioural changes to safeguard people is of 
paramount importance this is something the individual has control 
over. But they have no control over what happens in a hospital or a 
clinic, in this they put their trust in me the doctor, nurse of 
clinical officer to provide the safest possible healthcare.
Knowing this and the dangers of AIDS and other blood born diseases, 
should we not then be striving to achieve the safest healthcare? I 
say it again, how in all honesty can I stand in front of the people 
in rural health clinics, in villages to address them on practicing 
safe sex, when I know that I am not providing the highest standard of 
health possible. How can one in all sincerity argue against making 
the safest healthcare equipment available?
It is not a case of choice between safe sex or safe health care, it 
is quite simply that people who have been and continue to be on the 
frontline of the fight against HIV/AIDS, who despite battling huge 
difficulties and odds have succeeded in doing tremendous work, simply 
asking for tools that will help in the fight. It is about the fight 
for the future and in this there is no controversy, whatever help can 
be given should be provided. Can anyone in all honesty give a reason 
why such help or assistance should not be rendered? If so let them 
come to these health clinics, look these health workers in the eye 
and say so.
Dr John Kiwanuka Ssemakula (MD, MPH)
380 Lexington Avenue, 42nd Floor 
New York, New York 10168, USA
Tel: +1-212-739-7893
Fax: +1-212-739-7923
Mobile: +1-917-292-5968

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