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P2P has been selected as Best Partner of the Year (21/22)

Dear Prof Enawgaw Glad to inform you that P2P has been selected as Best Partner of the Year (21/22) by the BDU-CMHS Senate Mandate in its meeting held on July 13/2022.We are proud to have such a partner committed to realizing a Triangular Partnership, networking of Heath professional diasporas to BDU-CMHS/TGSH, and overall North-South collaboration for the betterment of health care and education systems in Bahir Dar University and Ethiopia at large. My Heartfelt Congratulations! Prof. Yeshigeta Gelaw

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Dr. Electron Kebebew

In the Spotlight Section of this issue, we present the profile of none other than Dr. Electron Kebebew. He is an accomplished clinician and medical researcher of the first caliber. We were hoping to carry a full email interview on his illustrious career. However, despite repeated attempts on our part, and due to his busy schedule, we were not able to gather the interview in a timely manner for this issue. He was kind enough to share the link below. We will try to report the full interview in a future issue. The Newsletter sincerely believes Dr. Kebebew’s amazing career is an exemplar of excellence for upcoming clinicians and researchers to emulate: Click to see a Complete profile of Dr. Electron Kebebew

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Blood in stool: Colon cancer unless proven otherwise

Kebede Begna, MD Rochester, Minnesota As the saying goes “Prevention is better than cure” among one of the proven methods in preventing human maladies, colon cancer screening comes at the forefront. When I think of colorectal cancer, one person comes to my mind, the untimely death of one of the professors from one of the pioneer medical schools in Ethiopia. I did have the chance and privilege to give care to him. Some years ago I posted a letter on http://tenayistilign.com a blog that was started by Dr. Surafel Kebede, a nephrologist from Cleveland Clinic, with a title “the untimely death of a doctor”. He had had blood in his stool but ignored it after he made a self-diagnosis of hemorrhoids. The bloody bowel movement worsened during six weeks rural attachment service in Zewai, a small regional town that he went with the final year medical students. He did not seek medical attention soon. His friends concurred with his suspicion and attributed the worsening of symptoms to the diet and dehydration due to the rift valley miserable desert heat. Finally, he needed to be transported to Tikur-Anbessa hospital, the largest teaching hospital in a metropolitan city of more than 5 million people, due to intestinal obstruction. The surgeon, a friend of the professor, had to make a difficult decision of closing the abdomen without doing further surgery. The fungating mass arising from the rectum not only closed the outlet passage but spread to the entire abdomen and liver. There was no precedent of survival to a disease of such degree, let alone at that time and that place, even today in the age of molecular and targeted therapy. Worldwide, colorectal cancer is the second commonly diagnosed cancer after breast; and the third common in men after prostate and lung cancer. It is the second leading cause of cancer death in both sexes 1. Approximately one in three people with colorectal cancer die of their disease. Most may assume blood with stool as hemorrhoid, but it is a red herring, for the medical community. ANY BLOOD IN STOOL IS COLON CANCER unless proven otherwise. This is mainly the consequences of missing early diagnosis is a catastrophic event even in the resource excess or efficient countries where there are several treatment options. These days we have several options for screening colon cancer specially in the west and may range from occult blood in stool, cologuard (a stool test that identify DNA markers of colon cancer), sigmoidoscopy or colonoscopy, virtual or capsule colonoscopy, and others2,3. Which one is ideal for your situation is beyond this letter; it is strongly advised to discuss with your primary care physician or provider. By mere chance those who have the privilege to have the test should not hesitate if not offered, to do the first step, asking for one of the tests to be ordered for you, if you are in the age group 40-50. The exact recommendation varies based on several circumstances like family history of colon cancer. Generally, it is recommended to have some form of screening starting the age of 50 and then every 5-10 years. There are some reports indicating that colon cancer is becoming more common in younger age group and more on the right side of the colon, and as a result it is more asymptomatic 4. In resource mal-aligned countries it is also more common in the young and most also present at advanced stage at diagnosis 5. In hindsight, as an old adage by Benjamin Franklin “an ounce of prevention worth a pound of cure” is true, if he had sought medical advice when he first saw blood in his stool or if he was in a county where screening is the standard of care, the young life might have not been lost. He was a loss to his wife, young children, the medical community, and to the whole country. Screening has been shown to decrease colorectal cancer mortality in a number of studies; one module predicted that screening may account for the 53% of the observed decrease in colorectal mortality in the west 6 The take home messages 1) Do not consider blood in stool as trivial or benign without proper evaluation. It is colon cancer unless proven otherwise. 2) Strongly consider having one of the tests mentioned above if you are in the right age group. References 2018 G. Colorectal cancer. International Agency for Research on Cancer, WHO 2018. Lin JS, Piper MA, Perdue LA, et al. Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2016;315:2576-94. Force USPST, Bibbins-Domingo K, Grossman DC, et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2016;315:2564-75. Davis DM, Marcet JE, Frattini JC, Prather AD, Mateka JJ, Nfonsam VN. Is it time to lower the recommended screening age for colorectal cancer? J Am Coll Surg 2011;213:352-61. Asombang AW, Madsen R, Simuyandi M, et al. Descriptive analysis of colorectal cancer in Zambia, Southern Africa using the National Cancer Disease Hospital Database. Pan Afr Med J 2018;30:248. Edwards BK, Ward E, Kohler BA, et al. Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 2010;116:544-73.

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Digitizing patient data- some perspectives and recommendations for Ethiopia

Mulugeta Gebregziabher, PhD Professor and Vice Chair Department of Public Health Sciences Medical University of South Carolina E-mail: gebregz@musc.edu Introduction: An electronic medical record (EMR) is the systematized collection of electronically-stored demographics and health information (e.g., medical history, medications, test results, billing data, etc.) on patients in a digital format [1]. EMR systems are designed to store data accurately in searchable digital form to capture the state of a patient across time with key advantages that include (i) elimination of the need to track down a patient’s previous paper medical records allowing data to be accurate and legible; (ii) reducing data replication; (iii) extracting medical data to assess trends and long term changes in a patient; (iv) facilitating population-based studies. Countries have the choice of developing in-house software platform, purchasing commercial software, or opting for an open-source depending on the overall cost of the respective system and the value it adds to an existing paper-based system. In this short report, a comparative analysis of commercial systems and open-source systems to establish EMRs is provided in a resource-limited setting like Ethiopia. This, in its own way, can spur an on-going debate in the programmatic developments of setting up an electronic health information systems (eHIS) in Ethiopia and beyond. A literature review on EMR systems was conducted by searching major databases such as the Scopus (which includes MEDLINE and Embase), African Index Medicus, and IEEEXplore. Journal articles and conference proceedings, including ahead-of-print articles published in English from 2000 to 2018 (August) focusing on Ethiopia, Kenya, Rwanda, Tanzania, Mozambique, Uganda, Ghana, Botswana, Sierra Leone, South Africa were retrieved . The search strategy identified 1,103 citations. Studies that were published before 2000, written in a language other than English, or were not accessible without a fee were excluded. The winnowing process resulted in 35 final articles that were deemed relevant to the objectives of this report. The summary of the results of what systems to exist in these African countries is given in Table 1. Table 1. Summary information about EHR systems in selected sub-Saharan African countries Country EHR system Year introduced World Bank Classification by Income type Open-source or Commercial? Ethiopia Variety of local systems 2009 Low Both Kenya OpenMRS 2006 Low-middle Open-source Tanzania OpenMRS 2008 Low Open-source Uganda OpenMRS 2006 Low Open-source Rwanda OpenMRS 2006 Low Open-source Ghana Variety of local systems Not known Low-middle Both Botswana MEDITECH 2005 Upper-middle Commercial Sierra Leone OpenMRS 2014 Low Open-source South Africa OpenMRS, MEDITECH 2006, Upper-middle Open-source Mozambique OpenMRS 2008 Low Open-source Commercial systems: Some of the most commonly used commercial EHR systems include Epic, Cerner, MEDITECH, and InterSystems [2]. These commercial systems are mostly used in the United States, Europe, Latin America and to some extent in the Middle East, but not in SSA (need to expand SSA) countries with the exception of MEDITECH. MEDITECH South Africa Ltd has been operating in Southern African countries (South Africa, Botswana, and Namibia). The low penetration of commercial EHR vendors in Africa can be attributed to the substantial cost that is incurred [3]. Other challenges include: (i) product lifespan to ensure that vendors and products are long-lasting; and (ii) the vendor’s reliability for product customization to avoid further expenses. Out-of-the-box functionality may not meet all the requirements in a given setting. However, commercial systems have certain key advantages that make them attractive. Implementations typically require minimal programmer/configuration personnel [2, 3]. Vended products usually undergo extensive testing prior to rollout, provide warranties and liability insurance, and most importantly, vendors provide system support and maintenance, including updates, bug-fixes, security patches, and feature enhancements [2,3]. Open-source systems: Open-source software (OSS) allows users to adopt, modify, and redistribute the software subject to a number of possible license options [4]. OSS is developed by a community of volunteer programmers and it is a model for open collaboration [5]. There are several types of open source licenses. The prominent ones are approved by the Open Source Initiative (OSI), www.opensource.org. OSI-approved licenses have strong communities and are listed in the aforementioned link. Table 2 provides a comparative analysis open-source and commercial systems. It shows how much great care is necessary when identifying and selecting a reliable EHR system. Table 2:   Comparative and qualitative summary for commercial and open-source EHR systems Commercial Open-Source High cost and mostly used in developed countries Cost effective and mostly used in low-resource settings Focused on revenue and profit Focused on collaboration and volunteering Support can be readily available for as long as the vendor is in business Support can be limited since volunteers normally need to attend to another full-time role Limited room for feature enhancements Flexible for feature enhancements Easier to implement with full vendor support Needs skilled implementers Rarely built to have inter-operability with other systems OSS are mostly designed with the future including interoperability Provides warranties, liability insurance, bug fixes and resolution of security issues No warranties or liability insurance, and may take time to resolve bug or security issues High system cost on top of infrastructure, hardware and personnel costs makes it challenging to scale up at national level Free of charge system helps scale up at national level – infrastructure, hardware and personnel costs still applicable Status of EHR in Ethiopia: To date, no EHR system has been nationally deployed in Ethiopia. Some efforts to deploy EHR within referral hospitals occurred at a few universities. For example, SmartCare, a hybrid EHR system which has been running at Ayder Referral Hospital in Mekelle. A study on SmartCare across five hospitals in Ethiopia indicated some challenges with the implementation of this system [6], including the lack of dedicated IT support at a given site and double documentation (paper-based and EHR) causing dissatisfaction and inconsistency. Another EHR system, WHONET, is a free Windows-based database software developed for the management of laboratory data, with a focus on antimicrobial susceptibility test results [7]. WHONET has been available since 1989 through the World Health Organization (WHO) Collaborating Centre for Surveillance of Antimicrobial Resistance based at the Brigham and Women’s Hospital in Boston. The system is used by

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The health and environmental hazards of “festal” or disposable plastic bags and other disposable plastics in Ethiopia

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.

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The Coming of Age of Hospice and Palliative Medicine in Ethiopia

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).

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The wild side of infections, a complex and cryptic source of disease spillover to human, and an ecologically relevant interface in one health

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

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Message from Editor in Chief

The purpose of a Newsletter is typically to disseminate information on the activities of an organization, in this case that of People to People (P2P), Inc. While this remains to be the central mission of P2P e-Health Newsletter, it will also entertain articles on topical health issues in its various “sections.” The Newsletter is envisioned as a springboard for a future academic healthcare journal under a broader P2P umbrella. The next several issues will be a mix between news/events, especially pertinent to P2P, commentaries, reviews, opinions & other formal articles. It will be a quarterly publication coming out in January, April, July and October of each year. The editorial team will screen submissions to make sure that they are consistent with the purpose of the Newsletter. The team will also take the liberty to edit manuscripts for language and clarity, but in so doing will work closely with authors to improve the final version. Unlike the case is in a formal journal, submissions to this periodical publication do not undergo strict peer review process, unless they are written in academic style to a narrow audience. For this reason, there will be some latitude of flexibility in the style that articles are prepared and submitted. Healthcare delivery is a multidisciplinary endeavor encompassing medicine, pharmacy, nursing, microbiology, engineering, technology, health administration and biostatistics, as well as a host of other related fields. While all the disciplines help in the diagnoses, treatment and management of diseases in this modern age, healthcare banks heavily on state-of-the-art technology to deliver advanced, specialized and quality care. P2P e-Health Newsletter will attempt to highlight these aspects, in addition to featuring activities of P2P. A stand-alone healthcare approach belongs to the past. A unified care is a way to guaranteeing a timely delivery of health services, which in turn significantly affects the well-being of communities. This maiden Inaugural Issue (Volume 1, No 1) heralds the birth of a medium designed in such a way that healthcare workers both in Ethiopia and abroad can share their ideas on thematic & topical heath issues. The Newsletter will also accept papers from all contributors, so long as they meet the criteria that are outlined above. P2P Health Newsletter is co-edited by Fekadu Fullas (Editor in Chief), Mulugeta Gebregziabher (Associate Editor) and Zelalem Hailu (Assistant Editor). It is managed by Nebiyu Hailemariam and Yosef Bogale. The Editorial Board advises the editorial team on issues and topics that need to be covered by the Newsletter. Please join us in this exciting journey! Fekadu Fullas, RPh, PhD Sioux City, IA 51104, USA (Editor in Chief, P2P e-Health Newsletter)

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