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Apr 2005 |
The civil war and subsequent collapse of the healthcare system
have provoked a medical crisis in parts of Ivory Coast. Responding over the past
two years to high levels of malaria, malnutrition and other diseases, Medecins
Sans Frontieres (“MSF”) teams in the West of the country have encountered
an alarmingly high number of sexually transmitted infections (“STIs”).
These STIs lead to horrific complications in reproductive health and carry disease
to younger and younger segments of the population. While drastic in its own right,
the high level of STIs is also a clear indicator that HIV is spreading, making
prevention and treatment efforts all the more urgent.
| A patient arrives semi-conscious at the
Danané Hospital in northwestern Ivory Coast. She has abdominal pain, rebound
tenderness and no blood pressure can be detected. The concerned midwife finds
that the patient’s vaginal walls are encrusted with a thick solid discharge.
This is one of the worst cases of sexually transmitted infection that the midwife
has seen in her 20 years of experience. Despite immediate treatment by the hospital
staff, the patient goes into cardiac arrest and dies of septic shock. She was
13 years old. |
Even considering her age, the death of this girl is not an isolated incident.
MSF teams on the ground in western Ivory Coast have seen the numbers of women,
young people, and men with STIs that they treat rise to over 20% of the adult
population. Mobile clinic activities reach as many as 1,600 STI sufferers per
month. However a significant portion of the community with STIs remains undiagnosed,
untreated or undetected.
The STI crisis is not a side effect of personal behaviour, but rather a symptom
of conditions fuelled by war, displacement and economic desperation. MSF has been
working in western Ivory Coast since 2003. Given acute needs and the unstable
security situation, MSF’s interventions have particularly focused on western
Ivory Coast, working on both sides of the front lines. In this volatile area,
along the border with Liberia and Guinea, MSF bears witness to the crisis in STIs.
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"I am 60 years old and visit the clinic because my grandson
is not doing well. When the rebels came, they forced my son to join , but I refused.
They became very angry and tied my hands on my back and undressed me and put me
naked in the hot sun. My son and his wife ran into the bush when this all happened
and the rebels followed them. They never returned and I take care of my grandson
now as both his parents are dead. He is sick, has high fever and needs treatment.
I am happy with MSF being here because now the clinic is open and services are
good......because of the war all health services have stopped." |
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MEDICAL CRISIS
STIs Affect the Youth
Despite the high numbers of STIs there
is a lack of general awareness among young Ivorians about what an STI is or how
to prevent getting one. This lack of awareness and formal education leaves many
women and girls without the power to make choices regarding sex or pregnancy.
These young women need information, reliable and safe contraceptive measures and
access to effective treatment.
| A 14 year-old girl comes to a mobile clinic
complaining of general pain in her head and stomach. She does not know if she
is pregnant, but the nurse examining her finds that she is carrying both a baby
and an STI. The young girl reveals that she is not married but often has sex with
a boy in the military. She further explains that in return for the sex she gets
money, clothes and protection for her, her two brothers and one sister. |
Violence Against Women and Girls
The economic desperation, separation of families and the influx of soldiers which
impact young girls’ lives are accompanied by sexual violence, unwanted pregnancies,
and an increase in STIs. Women may not know that treatment services exist or that
they need to come within 48 hours of pregnancy if HIV and STI infection are to
be avoided. For many women, Danané Hospital is too far away; for others
the event is associated with domestic violence involving family or friends making
reporting the incident and looking for medical assistance difficult; and in some
cases soldiers were involved making the woman and her family afraid to report
the incident to authorities. Personal shame or stigmatization in the family or
community may also be hindering factors. Women need to be made aware that treatment
options exist if they can get to MSF clinics in time.
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Before the war there were many health centres staffed by government
nurses but these are all closed now and the staff has left the war zone. This
means most women do not have access to any health care either before, during or
after pregnancy and this has an impact on their health as well as that of their
children. MSF tries to alleviate this by having weekly mobile clinics in the far
away villages. |
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STIs Result in Pregnancy Complications
The high STI rate among girls is matched by an alarmingly high rate among pregnant
women. One third of pregnant women arriving in the Danané Hospital for
external consultations have an STI.
| An 18-year-old woman walks 11 kilometers
to reach an MSF mobile clinic to be seen for lower abdominal pain and “general
weakness.” An initial examination leads to an urgent referral to Danané
Hospital over an hour’s drive away. On arrival the hospital staff confirm
that the young woman has a ruptured ectopic pregnancy and take her into surgery.
With the first incision the young woman’s heart stops. Her abdomen is filled
with blood, her right fallopian tube is ruptured and her left fallopian tube had
adhesions, an indicator of recurrent or chronic pelvic inflammatory disease. The
anesthetist manages to stabilize the young woman and the surgeon arrests the bleeding.
She survives the surgery and is discharged after two weeks in the hospital. She
will probably never be able to have children. |
This case is one of many such women seen in MSF’s clinics and hospitals.
The prevalence of ectopic pregnancies is directly related to high prevalence of
STIs among women seen by MSF staff. The lack of maternal health services leave
pregnant women with insufficient access to education and antenatal care. Also,
due to insecurity, midwives are often afraid to work in the western or northern
parts of Ivory Coast. In addition to a lack of staff, access to medical facilities
also is limited. For most of the West, the nearest place to get a blood transfusion
is Danané Hospital.
High STI Rates Correspond to High HIV/AIDS Rates
STIs include HIV/AIDS. AIDS, a consequence of infection with HIV (human immunodeficiency
virus), can be transmitted in the same way as syphilis or gonorrhoea. Infection
with these and other STIs increases vulnerability to HIV infection.
| A young man comes to an MSF mobile clinic
due to an extreme burning sensation when he urinates. He pulls out his wife’s
antenatal consultation book where “rendezvous parténaire” has
been written in red. His wife first came for treatment of an STI and now he has
come based on her referral. This is his first visit to the clinic, but not the
first time he has had the problem. In the past he took traditional medicines,
but the problem kept coming back. He does not use condoms because he says he cannot
find any in the market place. At the end of the examination and after confirmation
of his STI, the nurse writes out his prescription. She asks if he might have any
sexual partners other than his wife. “Oh no, well yes… my wife is
breastfeeding so I have a camarade…but she is pregnant now, so I have another
friend as well….” The nurse asks him to ask them to also come for
an examination. |
Despite an approximate 10% prevalence rate for HIV in Ivory Coast , to date
little has been done to combat HIV/AIDS outside the major city centers. MSF investigations
reveal that there are not enough condoms available in the shops or markets.
With STI consultations accounting for more than 20% of all adult consultations,
MSF staff fear that the HIV/AIDS prevalence is high. With priority given to children
under five and emergency cases, MSF staff often turn away up to 100 people, mainly
adults, at the end of the consultation day due to a lack of time and medical staff.
The only HIV testing that is currently done is for emergency blood transfusions
and they are done using Rapid Diagnostic Tests that are not reliable enough for
a conclusive diagnosis. This testing reveals that 17.1% of the blood transfusion
supply is HIV positive.
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Not only is access to STI or HIV testing a problem, but also there
are not yet any counselling services to prepare people for the results. MSF teams
are frustrated by treating alarmingly high numbers of STIs while little is being
done to prevent the spread of the infections including HIV/AIDS. MSF doctors and
nurses have begun to compile data and pictures to introduce into teaching sessions
between clinic consultations, but clearly more actors are needed to help in raising
awareness and promoting preventative measures. In addition there is an increasing
need for the Prevention of Mother to Child transmission of HIV, the treatment
of opportunistic infections and the treatment of AIDS with effective medication.
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LIMITED HEALTH SERVICES
Limited Programming in Western Ivory Coast
In addition to the lack of Ministry of Health (MOH) structures, western Ivory
Coast is fraught with insecurity which only aggravates the collapse of the health
care system. Currently only MSF and a handful of MOH, traditional and private
practitioners remain in the western region.
Due to the general instability, it is difficult to get personnel and supplies
into this area. In addition there is little information in western Ivory Coast
regarding sexual and reproductive health and where this awareness exists, preventative
measures such as condoms are unavailable. The combination of a lack of functioning
health care structures, general poverty and insecurity only fuels the rise of
STIs.
Economic Downturn and Influx of Soldiers
Once one of the wealthiest countries in West Africa, Ivory Coast is now in economic
crisis with the flight of investment capital and the suspension of bilateral aid
programmes. The crisis has resulted in economic des.peration. According to MSF
nurses in Danané, families marry off their young girls at an earlier age
in order to obtain the economic means to feed the rest of their family.
In addition, since the division of the country and the 2003 ceasefire there
has been an increased deployment of soldiers throughout Ivory Coast. Economic
insecurity and an influx of troops create a breeding ground for STIs. The situation
in the West has forced increasing numbers of women to engage in sex as a survival
tool.
RESPONSE TO HEALTH CRISIS NEEDED NOW
The war and tenuous ceasefire in Ivory Coast have directly resulted in a collapse
in governmental structures and infrastructure resulting in a lack of regular access
to health care for over 350,000 Ivorians. The spread of STIs corresponds to the
spread of HIV/AIDS. UNAIDS in their 2005 report have declared that AIDS could
kill 80 million Africans by 2025. Infections could soar to 90 million - or more
than 10% of the continent's population - if more is not done soon to fight the
disease.
With already the highest HIV rates in West Africa, Ivorians still have a chance
to act to prevent its spread and to assist those already affected. Local and national
authorities from Ivory Coast must respond and develop solutions to the alarming
rise in STIs. The development of solutions also falls into the hands of international
actors including the UN and INGOs. The solutions require actors with a commitment
to preventing the spread of STIs and the inevitable spread of HIV/AIDS. As witnessed
by MSF teams on the ground, this commitment has to go beyond merely establishing
a presence on the ground, but requires going into villages to reach the people
most at risk.
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