Hepatitis e and corona outbreak
An opportunity to strengthen public health, an analysis by Dr Pandu Hailonga-van Dijk
The past year Namibia has seen several Cholera and Hepatitis E cases. Hepatitis E is a liver disease caused by infection with a virus known as the hepatitis E virus, that is transmitted via the fecal-oral route, principally via contaminated water. A total of 6151 Hepatitis E cases were reported between September 2017 and August 2019 with Khomas region reporting the highest affected rate at 63% cases, followed by Erongo at 23%. These cases are often reported in informal settlements, this is especially so as many of the informal settlements have poor hygiene and lack sanitation. The majority of these communities practice open defecation. This reality let to the reaction of Government, notable Ministry of Health with the support of International Community notable, World Health Organisation and UNICEF. The focus has been on washing hands and even provision has been made to provide as seen below. Interestingly, when I visited the informal settlement the handwashing instruments seems left and standing all by themselves, lonely with no one taking ownership. It seems the last time it was touched was on the day it was brought into the community.
There are several lessons learned from the Hepatitis E
Hepatitis E exposed the poor public health system, lack of coordination and accountability. The challenge is that the focus in addressing Hepatitis E was on curative care treating the sick, providing handwashing facilities, with not necessarily addressing the root causes. For example, immediately with the outbreak, there were high-level visits and the quick provision of handwashing tap. The provision of tap water, and requiring people to continuously wash their hands, in a community where there are no taps overall, expected to buy water. With high unemployment, poverty communities will rather buy water for their needs and not necessary to wash hands.
The main causes of Hepatitis E are poor hygiene and lack of sanitation, and lack of education. This means that to address Hepatitis E there is a need to provide quality water, ensure that there is adequate sewage system and educate the community about the danger of defecating in the open.
The response to Hepatitis E seems to lack key elements. What was missing was a strong campaign on the causes and how to prevent similar outbreaks. Yes, it is possible to mobilize soldiers, students (studying health-related subjects) to get them in the community and let them educate the community and mobilize communities to build latrines. This reaction may have been contributed to a weak public health system/agenda/policy – to guide what to do in an outbreak. Limited coordination between key entities Health, local government, education, government, and non-governmental organizations.
Hepatitis E outbreak exposes the country and its lack of accountability and responsibilities. The so-called zero action, which I defined as the four characteristics of inaction that I refer to as the SEAN i.e. S-somebody who thinks that E-Everybody will address the problem and who turn thinks that A-Anybody will do it and at the end N – Nobody does anything. Forcing the question, who is responsible to address Hepatitis E. Which entity is in charge?
Hepatitis E is a health issue and seen as the problem of the Ministry of Health, however, its causes are outside the control of the Ministry of Health. The main cause of Hepatitis E is poor water and hygiene and lack of sanitation facilities. Entities responsible for water and sanitation are Municipalities and the Ministry of Agriculture and rural. Thus someone needs to be held accountable and should keep track of the situation, and also the country should be open and stop the silences around Hepatitis E and open defecation. Sadly even institutions of learning such as school are confronted with lack of sanitation and with learners defecating in the open.
Health system in Namibia
The challenge is that health systems in Namibia are decentralized with significant rural-urban disparities and also disparities within the cities. For example, in Windhoek central part of the country within a radius of fewer than 10 km, one finds 3 main hospitals Catholic, Central, Rhino Park and Medicity with several private doctors, etc. However, 10 -15km on the outskirts of Katutura with a population of over 200 000 is one hospital, 1 health center, and few clinics. People living in the outskirts have challenges with the accessibility, availability, and affordability for services. For example, in Okahandja park/Kilimandjaro is the only health service a clinic that is only open between 08h00-17h00 and closed over the weekends. Furthermore, there are challenges in reaching the nearest hospital as the transport system is unreliable no public transport and communities have to rely on taxis or neighbors.
The presence of health facilities is not guaranteed that we are addressing the health challenges facing our communities. The majority of the diseases in our society notable diarrhoeal disease, HIV, Gender Based Violence, Tuberculosis and Malaria, teenage/learner pregnancies are all preventable. Paradoxically our focus as a country has been on curative care. For example, 90% of the health budget is towards curative care with less than 10% on prevention. Hence the need to strengthen public health. Public Health System, Public Health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988; WHO).
Corona crisis turning this into an opportunity
The presence of Coronavirus provides opportunities to address communicable diseases in our country. The suggestions below will assist the country as we address communicable diseases:
1) Strengthen public Health
– Public Health should be given the attention it needs with over 70% of diseases preventable. The situation is such that close to 90% of the health budget is for curative care.
– There is a need to ensure human resources and finances are made available, time to get out of the hospital into the community to educate communities. Strengthen the work of Health extension workers, health inspectors, public health practitioners, etc.
– At the population and community level is it possible to implement the following to reduce Hepatitis E:
o Improve the provision of potable water and make it affordable and accessible
o Establish proper waste disposal facilities for human faces
• At the individual level educate and urge individuals to maintain hygienic practices including proper disposal of feces. Individual responsibility should be promoted – thus if all individuals wash their hands, properly dispose of their faeces – than we will be able to protect the entire society
• Ensure that we have a database of health professionals, including a rooster who can be mobilized at short notice.
• Waste disposal and improve sanitation should be treated as a matter of urgency
2) Academic Institutions:
– Strengthen public health training in Academia:
– Academic Institutions such as UNAM, NUST, IUM, and Welwichia as knowledge centers should guide government and Ministries on how they should address communicable diseases. They should carry out relevant research and make recommendations accordingly. They should be one taking precautions
– Academic institutions should promote community engagement and service‐learning, and ensure that there is a balance between theory and practice. Students should be exposed to the community and the challenges facing the community.
3) International organizations:
– International organizations’ support should be to strengthening community and public health systems. Most importantly, international consultants should team up with local consultants and international organizations should avoid working in silos but to collaborate and consider strengthening the local institutions. The focus should be on long term solutions that are sustainable. For example, if one educates and empowers individuals to build toilets and to properly dispose of faeces. Also, strengthen policies that address the root causes of the disease.
4) Evidence-based reporting
– Strengthen evidence-based reporting, and ensure that there is a central place where all the data are held and be available.
– Create comprehensive reporting systems
Lessons from Hepatitis E inaction requires that everyone take action. Starting with individuals, community, and Governors, in particular, should be held accountable for allowing mushrooming of informal settlements with lack of sanitation. This is one condition that one could control the situation if people do not have proper sanitation that they cannot settle in an open space??
By: Pandu Hailonga-van Dijk (Ph.D.)
Pandu is a public health expert and works as consultant and academic director for Seahorse Research and Training Institute