Covid vaccine market opens door to a burgeoning counterfeit medicines trade

New posters have popped up on the streets of South Africa advertising ‘vaccination R150’. At first glance they could be referring to any vaccine, but COVID-19 is likely the disease in question. And recent incidents suggest there is cause for concern.

In November 2020, the South African Police Service raided a warehouse in Germiston east of Johannesburg and discovered a consignment of packages resembling COVID-19 vaccines. They comprised around 2 400 fake doses and large quantities of counterfeit N95 face masks that originated from China worth around R6 million (US$40 000). Days later, INTERPOL issued an orange notice warning for law enforcement agencies worldwide of organised crime networks advertising, selling and administering fake COVID-19 vaccines.

COVID-19 vaccination is intended to provide immunity against Covid-19, but fake vaccines are already entering the market in South Africa. Photo: Getty Images

In February, police in China dismantled a criminal network responsible for producing and selling water as COVID-19 vaccine shots in Kunshan, eastern China. Police had arrested the syndicate leader in December 2020. It isn’t clear if the fake vaccines seized in South Africa originated from this network, but the syndicate did ship an estimated 600 doses abroad (destination unspecified) on 12 November 2020.

South Africa isn’t the only African country threatened by criminal networks trafficking fake medicines. Counterfeit vaccines have been reported only in South Africa, but this form of organised crime will eventually reach other African countries given the rise in COVID-19 cases on the continent.

Fake medicines are pharmaceutical products sold to deceive the buyers regarding the contents. These products are misbranded, often contain the wrong active ingredient or even toxic substances, and are manufactured by unqualified personnel.

The illegal trade in counterfeit medicines presents a significant threat to Africa. In addition to the negative impact on markets, economies and livelihoods, it also severely affects the health sector. ENACT research shows that these products help spread drug-resistant illness and undermine confidence in health professionals and systems.

Experts believe fake medicines and supplies are the most lucrative sector within the counterfeit market. While the market size is difficult to measure, it’s estimated to be billions of US dollars annually. Africa bears the brunt of this.

The World Health Organization reports that between 2013 and 2017, 42% of all cases of counterfeit medication reported were in Africa. However, this figure was probably higher, considering that not all cases are reported.

Mobilising on all fronts against a common enemy

Youth: Fighting COVID-19 their way

Africa’s young people are using resourcefulness and new technologies to engage and make a difference in the battle against the virus

Ndlovu Youth Choir “America’s Got Talent” Season 14 Live Show Red Carpet at Dolby Theatre on September 17, 2019 in Hollywood, California. Photo: Frazer Harrison/Getty Images/AFP

As Africa continues to battle COVID-19, the continent’s youth are not sitting idly by waiting for the worst to come. Across the continent, young people are hard at work, in partnership with governments and diverse partners, providing solutions to help reduce the spread of the virus and ways to address the socioeconomic impact of the pandemic, through engagements and innovation. In Egypt, Mohamed Elkholy, 25, is using new technologies to engage young people, fight misinformation about COVID-19 and spread the right messages about the virus. Mohamed, the leader of youth network Y-Peer Egypt, has been hosting a youth-to-youth podcast programme to create awareness among young people. In a country like Egypt, where youth constitute some 60% of the population, finding effective ways to engage young people and empower them is important in the battle against the pandemic.

Gwendolyn Myers, a 29-year-old peace activist, is co-chairing the National Youth Taskforce Against COVID-19 in Liberia. The task force was set up under the auspices of Liberia’s Ministry of Youth and Sports, bringing together five youth-led organisations. It was established to mobilise and build young people, empowering them to to lead campaigns against the pandemic in local communities. The task force, for example, uses young people at grassroots levels to ensure food is distributed to vulnerable sectors of the population, and to distribute essential sanitary material in high-risk virus hotspots such as slum communities and informal settlements with large populations and a limited supply of social services. In East Africa, Kibra Green is a youth organisation in Kenya’s largest slum, Kibera, in the capital Nairobi. The group is passionate about the localised implementation of the United Nations Sustainable Development Goals (SDGs), including SDG 3 on health and wellbeing.

The group has been engaged in several initiatives to mitigate and reduce the spread of COVID-19. Alfred Otieno, a leading member of Kibra Green, believes that youth have a critical role to play in the fight against the virus. In their case, the group, in partnership with UN-Habitat and Médecins Sans Frontières (Doctors without Borders), has set up hand-washing stations for residents, enabling them to sanitise. The group has also handed out masks, disseminated relevant information about COVID-19 and prevention, as well distributed food and other essential items to vulnerable families, including sanitary pads to needy girls. Kennedy Odede, the CEO and founder of Shining Hope for Communities (SHOFCO), a grassroots organisation that offers support to several hundred thousand slum residents in Nairobi, argues that youth are in the majority on the continent and yet most of the time young people find themselves marginalised. “We can’t win this COVID-19 war if the youth are not involved,” Odede says.

Mohammed Elkholy spreads the right messages about COVID-19. Photo: Raphael Obonyo

“We have a new youth in Africa who will not follow orders. This new youth want to be listened to, not told what to do. They believe they have the solutions. Now let’s tap on them to fight COVID-19.” In Democratic Republic of Congo (DRC), Christella Kiakuba, 26, an orphan of military parents and co-founder of community organisation Telema Mwana Ya Mapinga, is helping women and orphans protect themselves from the coronavirus. She is distributing face masks and showing people how to use them, and how to sanitise. She and her organisation deliver food and provide legal help to widows and orphans. In Cameroon, Achaleke Christian, the national coordinator of civil society organisation Local Youth Corner, launched a “One Person, One Sanitiser” campaign in April to prevent the spread of coronavirus, especially among the poor.

He and members of the youth group have produced homemade hand sanitisers using World Health Organization standards and distributed them for free, teaming up with a coalition of youth civil society organisations, medical doctors, pharmacists and a laboratory scientist in the process. In South Africa, young people have been at the forefront of government and community efforts to educate people about the basic preventive measures to help curb the spread of COVID-19. One example is 750Amped, a national campaign launched in May by South Africa’s National Department of Health and the Health and Welfare Sector Education and Training Authority (HWSETA). The initiative, which involved the initial training of 750 learners, was established as “a proactive intervention that leverages the power of youth to inspire changes in social behaviour through training, education, and awareness around COVID-19”, according to the 750Amped website.

Kibra Green is a youth organisation engaged in initiatives to mitigate the spread of COVID-19 in Kibera, Nairobi. Photo: Raphael Obonyo

Young South Africans have also used the power of music to encourage their communities to practise preventative measures against the virus. The Ndlovu Youth Choir, which was originally formed in 2008 by a Dutch doctor, working in South Africa’s largely rural Limpopo province to help orphans and the children of Aids patients, became a global phenomenon when they reached the finals of the TV show America’s Got Talent. They were forced to cancel an international tour when COVID-19 swept the world, but since then a video of a new song, in isiZulu with English subtitles, that demonstrates how to practise basic preventative measures, has gone viral. North of the border, in Zimbabwe, Bridget Mutsinze, 25, is among a group of youth volunteers working with development organisation Voluntary Service Overseas (VOS), using social media to fight coronavirus misinformation.

They have taken to Twitter, WhatsApp, Facebook and radio to comb through online comments, to identify and correct COVID-19 misinformation. In Côte d’Ivoire, Ibrahima Diabate and the Youth Peace and Security Network recorded a series of awareness-raising videos in different local languages to disseminate the much-needed information about coronavirus. The videos went viral on social media platforms. The use of local languages, and the cultural translation of the messages in ways that make sense to the communities they target, have enhanced their accessibility. And telling the stories of life under COVID-19, in this case among poor and marginalised communities in southern Africa, are dynamic young journalists like the team at Tazama World Media in Kenya, led by James Smart and Kizito Gamba in Kenya, who are dedicated to community-based journalism using smart phones and social media.

As South Africa’s Sport, Arts and Culture Minister Nathi Mthethwa said when he launched youth month 2020 on 2 June, recalling the role of young people in fighting the country’s apartheid regime: “The youth of 2020 have been called upon to fight a much more silent war, the coronavirus pandemic, and to help rebuild a society post COVID-19.” As Mthethwa correctly noted in his address, young people have a major role to play in the fight against the coronavirus – because youth are Africa’s greatest asset and the future of the continent depends on them.

COVID-19 means faith, hope and a plan

Nigeria: the long haul

The West African country’s frontline healthcare workers have gained a wealth of experience with Lassa fever and other pandemics, so it’s about getting on with the job

A health worker works on a sample during a community COVID-19 coronavirus testing campaign in Abuja on April 15, 2020. – The Nigerian government commence search and sample collections of eligible cases as they struggle to contain the COVID-19 coronavirus pandemic as cases rise in Nigeria amidst lockdown. (Photo by Kola SULAIMON / AFP)

Widely referred to as Dr Biddie among his peers and other healthcare workers, Ayodele Bidemi knows the emergency department of Nigeria’s first teaching hospital, the University College Hospital Ibadan, inside out. He has spent nearly two decades in the tertiary health facility as a student, house officer and clinical resident, but COVID-19 has been nothing like anything else he and his colleagues at the unit have had to deal with – both in terms of stress and the risk to their own health. During the early days of the pandemic, when community spread was not yet underway, there was very little information on the pandemic, and the hysteria around the disease meant that more people visited emergency rooms like the one where Bidemi works.

“Patients would say, ‘I have a cough or fever, I may have COVID-19’. Having a cough or fever doesn’t mean someone has COVID-19, as it may be a symptom of stress, but patients are not like that,” Bidemi said. “Because of the hysteria created around COVID-19, when people started coughing, they came to the hospital.” And as the outbreak shifted from individual imported cases to community spread, the unit had to evolve new means of keeping its workers safe, while also meeting the emergency healthcare needs of the city. “The Accident and Emergency Unit was barricaded at some point to limit the movement of people. We had only one entry and one exit point. Back then, if a patient was brought to the casualty section and had Covid-like symptoms, they would not be handled or admitted, but would be sent to the dedicated COVID-19 isolation centre in another part of the city,” Bidemi told Africa in Fact.

This approach was to prevent exposing other patients and health workers to the disease while also attempting to ensure that emergency care for accident victims and others was not disrupted. The paucity of PPE has been a well-reported global phenomenon that also challenged health institutions in Nigeria. “Initially, we reserved the available masks for those who came into contact with patients, because we were not sure when we would get our next supply; KN95 masks became very expensive and hard to come by,” said Nurse Abimbola Oluseun, an emergency room (ER) nursing officer at Jericho Chest Clinic, a secondary health facility in the south-west region of Nigeria that was one of the first places where patients suspected of having COVID-19 were referred to and admitted.

With no certainty when the next batch of PPEs would arrive at hospitals, clinics and individual health workers had to find other means of protecting themselves, leading to a wide array of face masks and ingenious deployment of new waste bags for PPE purposes. Bidemi said they took solace in the fact that even in countries where shortages were not as acute as in Nigeria, health workers were still testing positive for the disease. “It became obvious that health workers contracting the virus in spite of wearing PPEs likely got infected in the process of taking the PPEs off,” he said. “So we became very conscious of that essential step, irrespective of how many or how few PPEs we had.” Moreover, considering ERs cannot be quickly expanded, to achieve some form of social distancing, call duty rosters for various cadres of health workers were revised.

“Instead of the usual three shifts daily roster, it was reduced to two (8am to 6pm and 6pm to 8am),” Bidemi said. When the pandemic began, hospitals had to decongest wards, and patients who were not severely ill were quickly discharged, while those reporting to the ER for mild cases were given prescriptions and sent back home. Patients who could be managed at home were asked to go home. Despite these efforts, however, the ER workers were still at risk of exposure, especially by patients hiding their COVID-19 status. This was the case in several health facilities across Nigeria, including the University of Benin Teaching Hospital (UBTH) in Edo State, where 25 health workers were exposed to COVID-19 in early April after three patients who were rushed to the ER hid their travel history. By 27 August, Nigeria had recorded 53,317 cases of COVID-19, with 40,726 people discharged and 1,011 deaths.

Although lockdown measures have eased since they were imposed in March, the federal government announced on 6 August that the second phase of the eased lockdown would be extended by four weeks. As the numbers rise, doctors and other health workers at the frontline remain at risk. In June, the BBC reported that Nigeria’s National Association of Resident Doctors (NARD) had raised concerns about the number of infections and deaths among health workers, saying that 10 doctors had died. In Bidemi’s ER, four out of the group of six doctors had tested positive but had recovered and gone back to work. Although PPE supplies are still not as satisfactorily ubiquitous as desired, the fear of contracting the virus has subsided among health workers since it became apparent that those with comorbidities were at highest risk, and most of the health workers that tested positive for COVID-19 had recovered.

With lockdowns easing and movement increasing, the World Health Organization (WHO) Regional Office for Africa has said it expects the number of cases to continue to rise. But with a comparatively lower case fatality ratio (CFR) than several other continents, moving on seems possible as long as local health systems are not overwhelmed and health workers at the frontline are not overstretched. Bidemi noted that the government had made a number of promises to healthcare personnel regarding life insurance, but for now, all they had was a COVID-19 hazard allowance and hope that COVID-19’s CFR remains low. “We were here during the Ebola outbreak. It was contained. There is still a Lassa fever outbreak underway that nobody is talking about. Our consolation is that COVID-19 is yet another disease that we have to be very careful about and protect ourselves against,” Bidemi said.

“A part of me feels like even if I have COVID-19, I will be fine. If you look at the disease, there is no cure. What we currently have is supportive management. And people are getting better, including my colleagues across the country that tested positive,” Bidemi said. “At the ER, we are doing our best to strengthen our immune systems. So I will say that we are still lucky, and we just have to do our best for those who will need critical care. This is the reason we continue to work and save as many lives as we can,” he said.

Paul Adepoju is a Nigeria-based freelance journalist, scientist, academic, and author. He covers science, health, tech and development in Africa for leading local and international media outlets. He’s also the founder of healthnews.ng. He is completing a doctorate in cell biology and genetics and holds several reporting awards.

Healthcare on call

Ghana: mHealth

Mobile healthcare services are making inroads into rural Ghana, offering people a chance to get essential healthcare services for the first time

A staff member prepares a drone for the delivery of medical supplies at the drone delivery service base run by operator Zipline in Omenako, 70 kilometres (40 miles) north of Accra on April 23, 2019. – Ghana launched a fleet of drones on April 24, 2019 to carry medical supplies to remote areas, with Ghana’s President declaring it would become the “world’s largest drone delivery service.” The craft are part of an ambitious plan to leapfrog problems of medical access in a country with poor roads. The drones have been flying test runs with blood and vaccines, but the project was officially inaugurated Wednesday at the main drone base in Omenako, 70 kilometres (40 miles) north of Accra. Operator Zipline, a US-based company, said the three other sites should be up and running by the end of 2019. The drones are planned to ferry 150 different medicines, blood, and vaccines to more than 2,000 clinics serving over 12 million people — roughly 40 percent of the population. (Photo by Ruth McDowall / AFP)

The International Labour Organization estimated in 2015 that 56% of people living in rural areas worldwide did not have access to essential healthcare services. And in Ghana today, many rural people can’t always get basic healthcare services such as antenatal check-ups and vaccinations, because there aren’t enough quality healthcare facilities or trained personnel. Mobile technology offers ways to address these gaps, by reducing costs and connecting people to healthcare providers. Mobile health, or mHealth, involves the use of portable devices to create, share and store information to improve patient safety and care. It includes using mobile phone applications such as SMS, voice calling and wireless data transmission to collect or disseminate health-related information, and to offer direct care in the form of advice. mHealth solutions have been used to monitor cardiovascular patients in China and the United States (US), for example.

And in Japan and South Africa, for example, mHealth allows people in remote areas of the country to communicate via wireless networks to get timely information to manage their own health. Ghana could be a good candidate for mHealth services because of its large, medically underserved rural population and its uptake of mobile technology. The World Bank reports that Ghana had a rural population of nearly 44% in 2018. The ratio of doctors to patients in rural regions is about 1:18,257 compared to 1:4,099 in an urban region. In contrast to the scarcity of health personnel in rural Ghana, the country has the highest mobile penetration in West Africa and already outperforms many of its regional peers. By the end of 2019, mobile technology adoption stood at 55%, higher than the regional average of 44.8%. This means a huge number of rural people could receive digital services.

In our study, (Elizabeth Oppong, Robert Ebo Hinson, Ogechi Adeola, Omotayo Muritala and John Paul Kosiba, 2018), which looked at the effect of mobile health service quality on user satisfaction and continual usage, we explored how mobile health could be used or improved as part of the effort to broaden access to maternal healthcare for rural Ghanaians. We developed a model to assess service quality in mHealth; we wanted to know which aspects of service quality would influence user satisfaction and continued use of an mHealth service. Our study found that the quality of human interaction – in other words the person providing the service – had a positive and significant relationship with user satisfaction. We also established that people who are more vulnerable to health-related challenges might show much interest in health innovation such as mHealth and might be more willing to continue to use the services than those who are healthy.

A mother helps her child onto a weighing scale during a medical check-up at Ewin Polyclinic in Cape Coast on April 30, 2019. – Ewim Polyclinic became the first in Ghana to roll out the Malaria vaccine Mosquirix. After Malawi, Ghana is the second country to launch the vaccine. Known by its lab initials as RTS,S but branded Mosquirix, the vaccine has passed lengthy scientific trials, which found it to be safe and reduced the risk of Malaria by nearly 40 percent. (Photo by CRISTINA ALDEHUELA / AFP)

Ghana has seen a proliferation of mHealth programmes, alongside increasing rates of phone usage in the population. At least 22 different projects have been piloted since 2004. The women surveyed in our study used mHealth services to monitor common pregnancy related issues like the rate of development of their babies and their own individual health. To assess service quality, we measured three dimensions: system quality (users’ perceptions of the technical level of communication); interaction quality (communication between service provider and consumer); and information quality (benefits of information services). All three mHealth quality dimensions were positive and significant to continual use. But we found that of the three mHealth service quality dimensions, interaction quality had the strongest relationship with user satisfaction. In other words, what mattered most to the women who used the service was communication with the service provider.

We found that more than the cost of acquiring a handset and reliable mobile networks, the patience of health personnel in explaining health issues and helping the respondents to navigate same, was the most important determinant of user satisfaction. This result contrasted with a study which found that all the service quality dimensions had a positive relationship with satisfaction. We also found a significant relationship between user satisfaction and continual usage. Women who were satisfied with the service said they would continue to use it. Rural women who perceived mHealth service costs (equipment and service access) as affordable also had a greater tendency to be satisfied and willing to continue using the system than those who considered it expensive, in the absence of alternative care. It could be argued that cost also contributes to continual usage and we found that the majority of the respondents (59%) were using shared phones from relatives and friends to access the services.

In spite of the importance of cost, we concluded that the human side of the service is what influences mHealth quality, user satisfaction and usage the most. Policymakers and service providers can learn from our findings. We recommend that health personnel should deliver timely services and provide the right service the first time. They should provide information that is safe for maternal healthcare and customised to individuals. Any additional cost such as an mHealth service fee might discourage rural women from using the service. Policymakers and service providers should consider developing and deploying innovative mHealth subsidy support schemes. Finally, managers of mHealth services should constantly identify the changing needs of their customers and continually improve their services accordingly.

The Ministry of Health and regional public sector health institutions could consider introducing or strengthening customer service units to oversee mHealth programmes. Service providers should also remember that societal needs change over time. Users’ desire for quality and preferences in technology services might change as they become more exposed to information technology and competitors’ services.

*This article appeared on The Conversation in July 2020.

Robert Ebo Hinson is a Professor of Marketing and Acting Director of the Office of Institutional Advancement at the University of Ghana. He holds a DPhil in Marketing from the University of Ghana and a PhD in International Business from the Aalborg University in Denmark.

Dying to give birth

Maternal mortality

Postpartum haemorrhage and obstetric fistula are two avoidable conditions that continue to kill and maim women in sub-Saharan Africa every year

Nigerien women suffering from obstetric fistula wait for a chance to be examined and eventually get surgery on July 16, 2008 at the Maradi hospital, southern Niger, as doctors from Turkish help association Deniz Feneri and Doctors Worldwide visit Niger to help some of the 200,000 fistula illness effected women in the country. Obstetric fistula, or vaginal fistula, is a severe medical condition in which a fistula (hole) develops between either the rectum and vagina or between the bladder and vagina after severe or failed childbirth, when adequate medical care is not available. The World Health Organization estimates that approximately 2 million women in Africa, Asia and the Arab region are living with the condition, and some 50,000 to 100,000 new cases develop each year. AFP PHOTO / MUSTAFA OZER (Photo by MUSTAFA OZER / AFP)

Atim (not her real name), from Nigeria’s southern state of Akwa Ibom, was barely a teenager when she was married off to a much older man. She would have preferred to have had a child when she was older, but that was completely out of her control and she found herself pregnant in the first year of her marriage. Her delivery was prolonged and difficult, which was further complicated by the fact that her hearing and speech are impaired. After attempting to cope with the distressing after effects of the difficult birth and with little understanding of what was causing them, Atim ended up at the Family Life and VVF (Vesicovaginal fistula) Hospital Mbribit Itam, in Akwa Ibom’s capital, Uyo. She had developed obstetric fistula. International NGO, the Fistula Foundation, describes an obstetric fistula as occurring when: “a mother has a prolonged, obstructed labour, but doesn’t have access to emergency medical care, such as a C-section.

She often labours in excruciating pain for days. Tragically, her baby usually dies.” For the women who survive this trauma, most of them from impoverished communities and often married young, the physical damage is extensive. Says the Fistula Foundation, “the mother’s contractions continually push the baby’s head against her pelvis. Soft tissues caught between the baby’s head and her pelvic bone become compressed, restricting the normal flow of blood”. The damage leaves holes – fistulae – between the woman’s vagina, bladder and rectum, causing lifelong chronic incontinence unless surgically repaired. Fortunately for Atim, she was saved by the intervention and experience of Dr Sunday Lengmang, who was on a routine visit to the hospital from Jos, in northern Nigeria. Lengmang, a renowned fistula care expert, carried out a two-stage surgery that relieved her of incontinence. Atim is one of the lucky ones; she is not only able to live a normal life thanks to Dr Lengmang, she also avoided becoming a statistic, among the more than 600,000 maternal deaths that occurred in Nigeria between 2005 and 2015, according to a 2019 World Health Organization (WHO) report.

Although there have been reductions in global maternal mortality rates, with a 38% drop per 100,000 live births between 2000 and 2017, the WHO worries that it is still unacceptably high, with “about 295,000 women (dying) during and following pregnancy and childbirth in 2017”. Most of these deaths (94%) occur in poorly-resourced countries, and most of them were avoidable. According to the WHO, sub-Saharan Africa and southern Asia accounted for approximately 86% of the estimated global maternal deaths in 2017. Two-thirds (196, 000) of these deaths were in sub-Saharan Africa alone, with Nigeria accounting for “nearly 20% of all global maternal deaths”, with “no less than 900,000 maternal near-miss cases occurring in the country”. Postpartum haemorrhage (PPH) is the leading cause of maternal deaths and accounts for about 35% of them. Annually, about 14 million women around the world suffer from PPH, with 99% of the deaths occurring in low- and middle-income countries like Nigeria, as opposed to just 1% in high-income countries.

Patients wait in a ward prio to undergo obstetric fistula repair surgery at the Mulago Hospital in Kampala on October 31, 2014. Millions of women in developing countries suffer from the obstetric fistula, a hole in the vagina or rectum caused by prolonged labour without treatment which means they leak urine uncontrollably, and also endure the social stigma arising as a result of it. More than about 200,000 Uganda women live with fistula, but there are 1,900 new cases annually — this is just above the 1,850 women who were treated surgically in 2013, according to a report by the United Nations Population Fund, which funds the majority of repairs through the Campaign to End Fistula. AFP PHOTO/ Isaac Kasamani (Photo by Isaac KASAMANI / AFP)

The late Humihani Yahaya, from Kogi State in Nigeria’s middle belt region, called her husband on 17 March, 2020 to let him know that she had successfully given birth to a baby girl. Shortly after that, he received a call telling him his wife had begun to bleed uncontrollably. Rather than taking her to the dysfunctional primary healthcare centre a few blocks from her home, her family struggled to get a vehicle to take her to a more functioning hospital, where she died on arrival. In Bwari, a satellite town in Nigeria’s federal capital territory, Nkechi Okonya, 32, the breadwinner of her family, who supported her husband and two children by petty trading, gave birth to premature triplets on 20 April 2018. But after delivering the first baby at the Bwari Primary Healthcare Centre, her labour stalled. “For hours, they kept telling her to push, thinking the baby left inside her was just one, but nothing came out so they referred her to Bwari General hospital,” her cousin, Chinwendu Ekwunife, told journalists.

After delivering the first baby at 9am, it was only at 5pm that day that she was wheeled into theatre. “She delivered the remaining two children, but was bleeding heavily,” Ekwunife said. “She took four pints of blood in less than 15 minutes.” Okonya died shortly afterwards. For many impoverished women like Atim, who do survive an obstructed labour, the price they pay is a life of constant incontinence, shame, social segregation and health problems. In 2018, the WHO estimated that more than two million young women were living with untreated obstetric fistula in Asia and sub-Saharan Africa. This is a situation that experts like Dr Henry Uro-Chukwu attribute to malfunctioning health systems. Uro- Chukwu is the Director: Training, Research and Mobilisation at the National Obstetric Fistula Centre (NOFIC), in Abakaliki, Ebonyi State, in Nigeria’s south-east region. He told Africa in Fact that the underlying cause is “the state of the health system; fistula is a reflection of a bad health system”.

In addressing the condition in Ebonyi, support first came from the United States Agency for International Development’s (USAID) Fistula Work Project, followed by the federal government’s interest in making the facility the first national VVF centre in Nigeria. The centre now receives patients on a regular basis from 17 states across Nigeria as well as some from neighbouring countries like Cameroon. Referring to a study conducted in Ebonyi State, Uro-Chukwu says there is another factor to be considered: poorly performed caesarean sections. The situation is similar in Kenya. Galgallo Golicha, project officer of the Safe Motherhood Project, Amref Health Africa in Kenya, told Africa in Fact that some of the new cases of obstetric fistula presenting for treatment at hospitals are the result of “the doctors accidentally puncturing the bladder and/or uterus” during caesarean sections or other pelvic surgeries. It is also impossible to ignore the cultural influences that raise the risk of fistula and PPH, adding to maternal mortality across sub-Saharan Africa.

These include a form of female genital mutilation, commonly called yankan gishiri in northern Nigeria, and which is also practised in Niger, early marriage and childbearing, and birthing in churches and homes. Other traditional practices that put women at risk include: the belief that surgical delivery by C-section and birthing in hospital are signs of the woman’s weakness; the culture of delivering the first child in the mother’s house; the belief that the husband has the sole right of consent for his wife to undergo any surgical procedure; and a preference or insistence that female personnel attend the birth. Ogochukwu Mbamalu, a senior medical officer at NOFIC, says that while fistula is rarely fatal in itself, the longterm consequences are devastating for patients. She points out that cultural practices, ostracisation and the stigma attached to fistula lead patients to suffer depression, and in some cases they become suicidal. She advocates that more attention be paid to helping patients with their mental health as part of their recovery process.

Salamatou Traore, founder of the DIMOL (Dignity) non-governmental organisation, speaks about obstetric fistula at the NGO’s health centre in Niamey on February 19, 2016. – Niger is in a fight against fistula — a medical condition that affects girls married too young. (Photo by ISSOUF SANOGO / AFP)

Meanwhile in Kenya, Golicha identifies the lack of fistula surgeons as the biggest obstacle to remedying the situation. Although Kenya is “navigating this by organising fistula repair camps at least twice a year in each region,” he says this is a very expensive approach, and unsustainable. African governments, and Nigeria in particular, have signed into various international conventions, but these all seem to be nine-day wonders. The governments appear to be doing little regarding implementation, said Lengmang, who strongly advocates that gender equality policies, universal education and universal health coverage are issues that could help in fighting and preventing these health challenges for women, thus assisting in reducing the maternal mortality rate.

Vanessa Offiong is a journalist in Nigeria, with experience in investigative, science and development journalism. Vanessa is Executive Director of The Black Banana Media & Development Initiative and a Health Systems Global fellow. She has won awards and has been published by the British Medical Journal’s Global Health Blog.
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