A boost for Safe Health Care in Africa
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
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
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