Opinions

Abebe Haregewoin, MD, Ph. D. Maryland, USA The scourge of “festal” aka plastic bags in Ethiopia and Africa Thousands of plastic factories all over the world and in Ethiopia are producing tons of plastic bags, which are very popularly and increasingly used by the Ethiopian people for shopping purposes because of its ease, cheap value and convenience.  However, their hazards on human and animal health and negative impact on the environment are never questioned or openly studied in any depth in our country. The scourge of plastic pollution has far-reaching environmental, animal and human health consequences all over the world including Ethiopia. Plastic trash discarded in the environment impacts communities on multiple levels: such discarded plastic bags filled with rainwater could attract malaria-carrying mosquitoes or breeding ground and aggravate this important health hazard. Dumped in rivers and lakes, plastic bags choke, strangle, and kill marine life. Plastic trash can block storm drains and cause flooding—a devastating 2015 flood in Ghana caused by plastic-blocked drains killed 150 people.  It is obvious that in recent years the blockage of storm drains in Addis and other major cities and towns in Ethiopia resulted in flooding of streets, swelling of rivers, and caused flood-related casualties and property destruction. Due to improper disposal systems, many stray animals end up consuming plastics and get entangled and suffocate to death or die due to intestinal obstruction. Many abattoirs find plastic bags in the intestines of animals that are slaughtered for public consumption. Thousands of animals worldwide including cow, goats, sheep, dolphins, turtles, whales, penguins are killed every year due to plastic bags. The ingested plastic bag remains intact even after the death and decomposition of the animal. Thus, it lies around in the landscape where another victim may ingest it. Harmful effects of “festal” is caused by breakdown products The most harmful effects of plastics beyond hideous tatters and refuse blowing in the wind actually occurs long after they seem to have disappeared from sight as they fester in the sun and breakdown into even more harmful tiny and microscopic particles due to a process known as photodegradation. These tiny particles known as microplastics become easily distributed in the environment and are impossible to clean up or remove and continue to wreak a havoc on the environment and pose danger to the food chain. It is estimated that complete degradation of plastic products in the environment can take up to one thousand years. The presence of these microplastics in rivers and lakes in Ethiopia is unknown. Toxic chemicals released during plastic manufacture processes are major sources of the negative environmental impact. A whole host of carcinogenic, neurotoxic, and hormone-disruptive chemicals are byproducts of plastic production, and they inevitably find their way into the environment through water, land, and through air pollution. Some of the more familiar compounds include vinyl chloride and dioxins (in PVC), benzene (in polystyrene), phthalates and other plasticizers (in PVC and others), formaldehyde, and bisphenol-A, or BPA (in polycarbonate). Many of these chemicals are persistent organic pollutants (POPs)—some of the most damaging toxins on the planet, owing to a combination of their persistence in the environment and their high levels of toxicity. Because of the omnipresence of plastics, the complexity of the substances that they release into the environment and the potential interaction of these substances, many questions exist on the safety of plastics for humans and the environment. One of the components of plastics known as biphosphenol A (BPA), which is considered a health hazard has been banned from use in baby bottles and other products in the USA and many other countries. Di-(2-ethylhexyl) phthalate (DEHP), often used in PVC products, leaches out easily and has been found to have negative impacts. Several rodent and human studies have reported correlations between DEHP exposure and harmful health effects, including changes to the female and male reproductive systems, increased waist circumference and insulin resistance. Plastic bags which carry hot foods in them can release harmful chemical contents into the food and thus cause long-term health problems. The good news – we can stop the scourge of “festal” in Ethiopia Some countries in Africa have recently had success in the fight against plastic pollution. Kenya’s ban on single-use plastic bags, the most radical in the world has already taken effect.  The Kenyan ban came in on 28 August 2017, threatening up to four years’ imprisonment or fines of $40,000 (£31,000) for anyone producing, selling – or even just carrying – a plastic bag. A year after Kenya announced the world’s toughest ban on plastic bags, and eight months after it was introduced, the authorities are claiming victory – so much so that other east African nations Uganda, Tanzania, Burundi and South Sudan are considering following suit. Rwanda, outlawed them in 2008. Eight other countries: Cameroon, Guinea-Bissau, Mali, Tanzania, Uganda, Ethiopia, Mauritania, and Malawi are considering bans. The Government of the Gambia decided to completely ban the importation of plastics into the country as of 1st July 2015. The Ethiopian partial ban on plastics can not be taken as a success story given it’s apparent lack of success due to inadequate monitoring and enforcement. The Kenyan success story has shown significant downstream effects on businesses, consumers and even jobs as a result of removing a once-ubiquitous feature of Kenyan life. “Our streets are generally cleaner which has brought with it a general ‘feel-good’ factor,” noted the enforcement director of the National Environment Management Authority. “You no longer see carrier bags flying around when it’s windy. Waterways are less obstructed. Fishermen on the coast and Lake Victoria are seeing few bags entangled in their nets.” In Nairobi’s shantytowns, one immediate impact was on the practice of defecating in a plastic bag, tying it up and then throwing it on to the tin roofs, a convenience known as “flying toilets”. The steps taken by the Kenyan ban on plastic bags has actually eliminated this odious flying problem as well as the more serious environmental and health hazards of plastic contamination of the food chain.

Anteneh Habte, MD Virginia, USA The history of pain and suffering is as old as mankind itself.  Prior to the advent of antibiotics in the early 20th century, most illnesses were invariably brief and fatal and the focus of medical care was primarily symptom relief.  The epidemiological transition to a gradual and prolonged decline with a high symptom burden is a relatively recent phenomenon. The concept of hospice care dates back to the time of the pilgrims when travelers were provided a place to rest during their long journey. It was only towards the end of the 19th century that hospice started becoming associated with terminal illness. The centers were for the most part run by community volunteers and civic organizations, and hardly interfaced with the health care structure. More recently, they were used as an alternative care setting by patients who were disillusioned by what modern medicine had to offer, or felt abandoned by their professional care providers.   In most of the resource-limited countries, particularly sub-Saharan Africa, hospice had been the only available option for HIV/AIDS care before the era of anti-retroviral drugs. Likewise, the hospice movement in Ethiopia started more as a response to the health system’s inadequacy to respond to the HIV/AIDS epidemic, than a desire to provide an alternative care setting.  A strong social fabric and communal responsibility for the sick has always been a basic tenet for Ethiopians and these elements bode well with modern hospice and palliative medicine. As one of the oldest nations in the world, Ethiopia has a rich history of traditional medicine and indigenous practices.  The rich heritage is holistic in nature and addresses not only a patient’s physical ailment, but also the psycho-social dimensions. This approach seamlessly integrates the physical and spiritual with traditional remedies and religious rituals, and is particularly relevant to palliative care where the emphasis is addressing “total pain” of patients and their families. Palliative medicine is a relatively new discipline that has emerged in the western world and developed nations as a response to the challenges of cancer and other chronic life-threatening illnesses such as advanced cardiac, pulmonary and neurologic disorders. Dr. Cicely Saunders widely recognized as the founder of the modern hospice movement, opened the first team-based facility in the United Kingdom in 1967. The integrated model of this discipline allows patients and physicians to navigate through the disease trajectory with appropriate adjustment of treatment goals as disease progresses and function declines. Over the last decade, Ethiopia has made significant strides towards integrating hospice and palliative medicine with the existing health care structure. A guideline for the standardization and implementation of palliative care has been established and morphine is now being locally constituted. Governmental entities, health care institutions, and civic advocacy groups have been raising public awareness and trying to dispel the stigma associated with hospice care. Opportunities for training, both pre-service and in-service, are expanding and physicians are increasingly recognizing their role in the continuum of care of their patients with advanced life-threatening illnesses. More recently, some health care institutions in Ethiopia have been able to meet the minimum World Health Organization (WHO) criteria for comprehensive hospice and palliative care services. This requires providing inter-disciplinary care which incorporates core members to address all the domains of suffering faced by patients with life-threatening illnesses and their families. Notable examples are the Hospice Ethiopia Organization and the Family Medicine Department of Tikur Anbessa Hospital.  Laudable efforts have been underway to incorporate palliative care into the pre-service curriculum and expand the availability and accessibility of opioids. The reach of these important services is being extended by empowering allied health personnel (task shifting), and strengthening associations and organizations that champion quality inter-disciplinary care through the disease continuum. The training and deployment of thousands of Health Extension Workers (HEW) to provide preventive and curative services has helped alleviate challenges of access to care in remote parts of the country. Much remains to be done to ensure quality end-of-life care to Ethiopia’s rapidly growing population. The extremely high rate of uncontrolled pain reported in some studies is a reminder that all health care professionals should have basic training and knowledge in symptom management.  Strong opioids, especially morphine, are the mainstay of treatment for pain related to advanced and progressive diseases. Ethiopia’s extremely low per capita use of opioids, 1.5mg of morphine equivalent, (2015 data from the International Narcotics Board) is indicative of inadequate pain management at the end of life. The rampant world-wide epidemic of opioid abuse notwithstanding, responsible and targeted use of these important medications is both possible and necessary. Ethiopia’s history and culture are uniquely conducive for such a “high touch, low tech” specialty as hospice and palliative medicine.  Providing holistic and comprehensive inter-disciplinary care to those with life-threatening illness is not just good medicine, it is both ethical and humane. Suggested Reading Mamo Y, Habte A: The History and Current Status of Hospice and Palliative Care; In Essentials of Palliative Medicine and Hospice Care; Temesgen Z (editor); Mayo Clinic eCurriculum Series, 2014 Kassaye KD, Amberbir A, Getachew B, Mussema,Y: (2006). A historical overview of traditional medicine practices and policy in Ethiopia. Ethiopian Journal of Health Development, 20, 127-134. World Health Organization (2005):  A Community Health Approach to Palliative Care for HIV/AIDS and Cancer Patients in Sub-Saharan Africa – Ethiopia Country Report. Hunt J:  Rapid assessment of Palliative care provision in Ethiopia. African Palliative Care Association (APCA), Funded by True Colors Trust 19th – 28th January 2008, Addis Ababa, Ethiopia. Anderson Reid E, Gudina EK, Ayers N, Tigineh W, Azmera YM: Caring for Life-Limiting Illness in Ethiopia: A Mixed-Methods Assessment of Outpatient Palliative Care Needs. Journal of Palliative Medicine, 2018, Volume 21, Number 5. Published online      1 May 2018 https://doi.org/10.1089/jpm.2017.0419 (last accessed 12/10/18).

Zelalem H. Mekuria DVM, PhD. Post-doctoral Scholar, School of Veterinary Medicine Louisianan State University, Baton Rouge, LA zmekuria1@lsu.edu History has it, that infectious diseases spared no country, social order or religious groups. The sheer magnitude sickness, suffering and deaths as a result were difficult to measure. Writers, philosophers and elites of the past have sampled some of the historical apocalypses in their work, while archeologists unearthed artifacts that are reflective of the then struggle, loss of life, as well as early attempts of disease prevention. These records suggest that infectious diseases existed as long as the human history itself (1, 2). The devastations caused by the Spanish flu, bubonic plaque, and small pox epidemics are ascribed in the annals of history. However, since the great Edward Jenner conceived the idea of vaccines, we have succeeded in controlling the outbreak of infectious diseases. In addition, the last century was marked by the discovery of antibiotics, which have greatly advanced the global effort of controlling epidemics. Despite all the progress, humanity still deals with problems of the Old Testament time. In this piece, I would like to identify two ancient pathogens that have managed to complete the long well documented inter-millennial journey to the present time, and continue to causes death and suffering particularly in the developing world. I will also highlight the role of wildlife/animal reservoirs in this process and project “one health” approach as a pertinent future strategy for the control/prevention of infectious diseases. The ancient Hebrew word Schachepeth (literal meaning wasting disease) in Deuteronomy and Leviticus is believed to be a biblical reference for Tuberculosis (TB), suggesting a pre-Christ existence (3). Archeological findings and the description of the lesions date back to predynastic Egypt (5000-5500 years) (1). However, modern molecular dating techniques allowed researchers to accurately estimate the age, which showed the current strain of Mycobacterium tuberculosis to have been around for 15,000 – 20,000 years within the human populations (4). Despite old age, the fact remains that 1.8 million people die annually from TB. The multifactorial nature of constraints surrounding global, national and regional TB control programs makes management somewhat problematic. The problem ranges from inadequacy and an outdated nature of diagnostic methodology, spreading of multi-drug resistant strains, poor socioeconomic condition, and high HIV co-infections rates. These factors are only a few of the limitations in the fight against TB. The second historical enemy is rabies, which has been accurately recognized in the ancient Mesopotamian document called the “codex Eshnunna”. In one of the articles, it stated that “if a person is bitten with dog showing rabies symptoms, and then later died, then the owner of the dog is to be heavily fined”(5). As result, the codex Eshununna is seen as the earliest fossil record of rabies virus circulation in humans and animals well before 2000 BC. It is one of the earliest attempts by humanity to legislate a public health issue. Fast forward to our time, rabies continues to be responsible for 59, 000 deaths each year,  and about 95% of the cases are in African and Asian countries(6). The most important commonality between the two infectious agents (Mycobacterium tuberculosis complex and Rabies virus) is that they crossed the host-specific barriers and effectively formed a multi-species adaptation. Owing to their successful story, attainment of such phenotype was perhaps an advantageous evolutionary path. For rabies, genomic plasticity, ability to produce many different genetic variants, allowed it to infect a range of hosts. By contrast, the different lineages of TB have diverged by fifteen to twenty thousand years, but each one of them maintained a zoonotic potential. Recent studies on the highly human adapted strain of Mycobacterium tuberculosis, demonstrated an ability to infect a Bovine species and has created an additional challenge to the puzzle (7). The ability to form a multi-species adaptation may seem a simple one, but it has significant ramifications that a pathogen able to infect multiple species may require transmission by multiple hosts. The consequence of this phenomenon is a very complicated pathogen biology with varying level of virulence and increasing the epidemiological risk factors to human exposure. For diseases like Rabies and TB, having a plethora of wildlife reservoirs creates cryptic sources of infection which are not accessible by regular monitoring, surveillance, control and eradication programs. In addition, the ecological complexities of these cryptic hosts facilitate considerable amount of persistence in the environment. On the other side, the direct impact of these infections on wild life and conservation efforts of endangered animal species is also paramount. A notable example in this regard is the case of an Ethiopian wolf (Canis Simensis), where successive rabies outbreaks reduced the population of rarest canid species in the world close to extinction (8). It may be hard to empirically justify, however, incidence of infectious disease spill-overs from wildlife to humans or from humans to wildlife is on the rise. The direct repercussions of human expansionism to new unexplored geographic territories, not only made us prey to old foes, but also increased the odds of exposure to infectious agents which were not native to us. This supposition is evidenced by the ever-increasing number of emerging infectious diseases from a wildlife origin. Here, some may argue with the advent of contemporary and real time diagnostic tools, we are only becoming better in identifying what has already existed. However, the scientific consensus seems to underscore the need for rigorous prediction, timely detection and well primed response capacities in areas where a convergence of risk factors may facilitate infectious diseases spillovers. It is also very important to note 75% of newly emerging, and re-emerging human pathogens are from wildlife/animal origins. Hence, such problems need to be tackled at the interface of human, animal and the environment. In this regard, “one health” “one medicine” is an approach/initiative which emphasizes collaborative management of health problems which otherwise are too heavy for any single discipline. The notion of one health relies on the principles that human, animal and environmental health are one continuum. It identifies the interfaces in each of the three to tackle