'Help us reconstruct the health system'

Interview with Dr. Ebrahim Samba, WHO Africa director

When travelling to meet donor officials outside Africa, which he does frequently as the Africa regional director of the World Health Organization (WHO), Dr. Ebrahim Samba often likes to shake their hands and remind them of what might happen if he were carrying Ebola or some other highly infectious illness. "If I were infected with any of these diseases, you risk being infected," he says. "You can stop Africans using passports and visas. But you cannot stop the infective agents, because they don't have passports and they don't need any visas."

-- Dr. Ebrahim Samba,
Africa regional director, World Health Organization

Photo: WHO

Therefore, Dr. Samba emphasized in an interview with Africa Recovery, "it is common sense, informed personal interest for the non-Africans in the developed world to help Africa fight against these infectious diseases.... The more Africans are supported to fight against the diseases that plague Africa today, the greater the security of the developed world" as well. To some extent, he believes, alarm over the AIDS crisis has helped to focus greater international attention toward the African continent, including its health conditions. "They are responding, slowly, slowly. But it's coming."

Drug access: a catalyst

Access by Africans to affordable medicines is vital to combat AIDS, malaria, tuberculosis and many other diseases, Dr. Samba insists. Often in his discussions with donor officials and pharmaceutical company executives, they ask: With Africa's health delivery system in such poor shape, will it be possible to actually deliver the medicines? Whatever the current weaknesses of Africa's health sector, that is no reason to delay providing the drugs themselves, he responds.

The shortcomings of Africa's health system are many, Dr. Samba acknowledges. He cites problems of under-staffing, under-funding, poor management and corruption. "There is no perfect health system in the world. The health systems in Africa are even less perfect. But they are not zero. They are in a very poor state, but they can be improved. And if we have the drugs, that can be a catalyst, that can act synergistically with all the resources locally and internationally to improve the health delivery system."

He cites the example of the struggle against river blindness in West Africa, a campaign he led during the 1980s and early 1990s before taking up his current position as regional director. During that campaign, he was able to negotiate with several pharmaceutical companies to provide free of charge a key drug used for treating the disease. The "health infrastructure" was in a very poor state, but "we trained the communities, illiterates, non-medical technicians to deliver these drugs using community-oriented delivery systems." The campaign was highly successful, and river blindness is no longer a major public health problem in much of the region.

Dr. Samba agrees that river blindness was "a very small problem" compared to the AIDS/HIV pandemic, which is far more complex and widespread, and for which no cure has yet been found. To face up to the challenge, Africa's hospitals, clinics, research facilities, doctors and nurses need much more funding than they currently have. "Give us the resources, and we will deliver," he pledges.

Besides, Dr. Samba adds, the donors themselves bear some responsibility for the state of Africa's health system. He remembers arguing with donor officials, "particularly the World Bank," about structural adjustment programmes, which led to reductions in the recruitment of qualified staff, freezes on their salaries and the removal of subsidies on essential drugs. "They contributed tremendously to the destruction of the health delivery system. Now they turn around and say: 'We wouldn't like to give you these drugs because your health delivery system is weak'." The donors eventually began to change their approach on structural adjustment, "by which time the systems had been severely damaged. Now it is their turn to help us reconstruct these systems."

Poverty and women

Commenting on remarks by South African President Thabo Mbeki and others about the correlation between Africa's widespread poverty and the HIV/AIDS pandemic, Dr. Samba agrees that "poverty is the foundation of many of our disease problems."

This relationship is more direct with some diseases than others, he points out. Cholera, for example, is more closely linked. "Only poor communities suffer from cholera," since they lack potable water, proper latrines and education about basic sanitary practices. AIDS, however, threatens everyone. "Some rich people suffer from HIV/AIDS, sons of millionaires, judges, lawyers, doctors, engineers, teachers." Yet at the same time, "it is no coincidence" that Africa has the highest poverty rates in the world and accounts for the largest share of the world's AIDS cases. "So there is a very close inter-relationship between poverty and HIV/AIDS." Poverty contributes, he says, "but poverty is not the only cause."

Among all sectors of the population, women are the most susceptible to HIV infection, Dr. Samba points out. "There is an increasing awareness that because of the physiology of women, because of the economic deprivation that women suffer, they are more vulnerable to AIDS," he says. "More women, particularly young ones, suffer from HIV/AIDS than boys. More women are dying of HIV/AIDS than men. And when women die the children are orphaned, because it is the women who look after the children. Presently there are over 12 million orphans in Africa. If we project this in the next 20 years, the social implications are frightening."

Besides tackling the disease itself, there are two essential ways to reduce women's particular vulnerability, Dr. Samba explains. "First, empowering women, increasing their status, giving them more education." Second "encouraging micro-economic activities to enable women to be sufficiently economically independent to say 'no' to unwanted sex, to insist on the use of condoms where it is necessary."

The AIDS crisis in Africa affects so many different sectors of the population and is so sweeping in scope that resolving it will require the energies of everyone, Africans and non-Africans alike, Dr. Samba concludes. "Let us work together in partnership, respecting each other and realizing that we are in this global village. We either sink together or float together. And we are going to float together."

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