Prepared by: Dr.Roy Rickman, MSc(Dist), PhD, DLSHTM, FIBiol.,FIBMS – formerly Senior WHO Scientist (working in Africa 1963 – 1984) and Senior Research Fellow, LSH&TM (1984 -1988). February 2006.

Mean % Rural of 9 other countries = 77.1

· Only comparatively few rural communities live within reasonable walking distance of a rural health post (e.g. 5 kilometres). Thus, if the rural health services are unable to reach them, for most of the time these outlying villages are medically incommunicado and those living there tend to walk or be carried to seek medical aid only when very sick and often too late to be cured.

2.Facilities:· Almost all outlying villages and clusters of small hamlets that are far from the nearest health centre are within easy walking distance of a school. It is suggested that these village schools could play a vital role in helping to control the major diseases and, through the children, improve community awareness of the health problems and what they can do to minimise them.· Many rural health services in sub-Saharan Africa are grossly under-funded and often have a poor capability for definitive diagnoses, due to the lack of more appropriate equipment that can function properly in the absence of generated electricity or vehicle battery access.· Also, without proper reliable transport, rural health service personnel are unable to establish and maintain regular and effective medical surveillance of outlying villages and schools in their catchment areas, especially if they have to cross rivers or flooded areas in the rains. (See also under Section 3).· Due to the lack of quality medical surveillance, treatment that is given at the RHC and later taken at home, is invariably unsupervised and may not be completed. Stopping treatment too soon, i.e. when symptoms start to subside and the patient feels better, carries the danger of inducing drug resistance and could seriously exacerbate the difficulties of disease control.

3. Prospects for major disease control programmes in developing countries. In recent months much international attention has been focused on funding and supporting specific actions needed to control the burgeoning health problems of developing countries, in particular HIV/AIDS, malaria and drug-resistant Tb. Large sums have been donated by several nations; Bill (& Melinda) Gates, the humanitarian genius of Microsoft, has generously donated more than 600 million dollars to boost the fundamental research needed to produce efficient vaccines against these common killer diseases and supply the insecticide-treated bed-nets. The successful mapping of the genomes of both 'cerebral' malaria (Plasmodium falciparum) and its Anopheline vector mosquito, coupled with encouraging research progress towards a reliable and effective vaccine against this major killer, especially of the Under-5s children, offers good hope for a successful outcome. However present research (in the laboratory and in Africa) suggests that specific vaccines may still take some time to perfect and make widely available to the many millions urgently in need of them. In the meantime there is still much that can and should be done, at comparatively little cost, to ease the present disease burden and lay a sound foundation on which future major control programmes can be laid. These activities would:-· Provide new, better diagnostic tools, accessories, appropriate medicaments and water sterilisation tablets (where appropriate) to District Hospitals, Rural Health Centres, Rural Village Clinics and Dispensaries.· If accepted - issue new 'Child-Safe' mosquito nets for all Under-5s children.· Provide new multi-geared bicycles (each fitted with the new pedal powered microhaematocrit centrifuge, dynamo, puncture-proof tyres and general medical kit).· Provide additional training as required to all Rural Health Staff in the use of the new instruments, in diagnosis and treatment and in accurate data collection/presentation.· Establish and maintain regular (monthly) effective medical surveillance of all outlying village communities and schools.· Use these visits to reduce the present disease burden with accurate and timely diagnoses followed by early and correct targeted treatment and advice. And to treat the other common conditions such as sores, wounds, ulcers and provide dressings and injections as necessary - before, during and after the vaccination programmes; also to give early warning of any incipient epidemicity.· Collect accurate epidemiological base-line data to support the later major control programmes.

4. Major disease considerations.

4.1. Anaemia· Many causes (blood loss, malnutrition, malaria, hookworm etc).· Need to identify type by microscopy – diagnose and measure either with simple centrifugation of small blood samples collected in new safer plastic capillary tubes or, most accurately, using the new Anaemascan battery/solar-powered Hb meter.· Especially important - check all young children, pregnant and nursing mothers and the aged regularly, both for initial diagnosis and for subsequent monitoring after treatment.

4.2. HIV/AIDS· It is clearly important that regular contact is established with all sections of the rural communities and all those with markedly low Hb levels and other symptoms such as marked weight loss, chronic diarrhoea, fever, candidiasis, peristent cough (Tb) incipient pneumonia (Pneumocystis carinii – refer for detection of antigen in sputum) should be checked for HIV/AIDS.· Regular medical surveillance must ensure that suspect positives are properly confirmed by a competent authority. · Ensure that adequate supplies of anti-retro-viral drugs, drugs for palliative care and for the treatment of opportunistic infections are available - but are administered only on informed medical advice.· Distribution of condoms – public awareness advice, especially to schools.

4.3. Malaria (Africa Malaria Report 2003, WHO/UNICEF publication).· A new mosquito net 4ft long has been designed specifically to protect very small children and cannot be commandeered by adults. Although it should be fully protective without insecticidal impregnation the added pyrethroid repellency would probably enhance its effectiveness. The net has special externally attached side protections panels (to prevent biting through the net) and is be fitted with two no-cost plastic-bottle mosquito traps. It is felt that this new net could be used to supplement the present on-going bed-net malaria control programmes. ((See drawing attached).· The simple plastic bottle mosquito trap has been designed to fit on top of the net using the sleeper’s rising ‘host odour’ as the mosquito attractant. This odour is concentrated both by the converging upper surfaces of the netting and also by the light cloth shield around the trap that additionally reduces loss of rising odour. Such traps could be made at virtually no cost by eg school children (as a practical item on the curriculum) or as a simple cottage industry. · Treatment – to reduce risk of further induced drug-resistance it is suggested that ‘home treatment’ is supervised by a special nominated Village Health Assistant** based at the school This would ensure that all treatment is taken properly and completed (many people stop taking the drugs as soon as they begin to feel better).· If possible involve all school-children in anti-malaria measures:a). making the plastic bottle mosquito traps.b) breeding Gambusia fish (which feed on mosquito larvae) - as a school science activity. c) identify and mark all local standing water that has Anopheline and Culicine larvae in it – then either cover with expanded polystyrene beads or seed with fish fry. ** If suitable and willing, such VHAs could later be given the opportunity for further training to help them become permanent staff members of the rural health service

4.4. Sleeping sicknessThis disease is still present in active foci; it is both endemic and widely enzootic in many wild animal species.Control: a). Regular medical surveillance to give early warning of epidemicity.b).Alert the local Tsetse Control Services to organise bush clearing around the area and set up traps and screens.d). Permission given for Suramin sodium (Antrypol) to be administered at the village level by local senior rural health personnel (a small 0.2g test dose must always be given first to guard against (rare) adverse reactions). One gram of Suramin clears both the blood and lymphatics of the infection and keeps them clear for 3 - 6 months (. By providing the rapid depletion and temporary elimination of the local (human) reservoirs of infection, Suramin would be an ideal weapon to control this disease and especially to control and prevent epidemicity. Pentamidine also serves a similar purpose but is more effective with T.b.gambiense infections (Apted, 1970, The African Trypanosomiases, pp. 685 – 689).

4.5. TUBERCULOSIS· Accurate diagnosis at the periphery is particularly difficult, ‘cough plates’ (sputum) can be stained (Ziehl-Neelsen) and examined microscopically but this is better done at the RHC level. Obtaining suitable sputum samples from children is very difficult; best to refer all adults and children with history of persistent cough.

4.6. HOOKWORM· Parasitic worms living in damp soil. Infection occurs through the feet – especially near water-gathering points.· Control by building better water holding facilities with varnished duckboard surrounds, building ventilated improved privies (VIPs) to prevent indiscriminate worm-infected defaecation – if affordable install swing- or seesaw-pumps to lift cleaner sub-surface water. (See drawings attached)

4.7 SCHISTOSOMIASIS· Snail-borne infections acquired in standing or sluggish water. Examine and mark all snail-infected ponds and sluggish streams with large’Danger’ signs for children.· Periodically clear weeds on which snails feed.· Build and encourage use of VIPs nearby – infection of water by urination in water and defaecation nearby (contaminants washed in by rain).

5.1 TRANSPORT· 4x4 vehicles are expensive to buy, run and maintain, and local servicing facilities are invariably lacking. It is suggested that strong, multi-geared bicycles equipped with the new pedal-powered microhaematocrit centrifuge, pannier medical kit, dynamo (for night emergencies) and puncture-proof tyres be supplied to all rural health staff engaged on surveillance work. To ensure serviceability, staff would keep the bicycles after 2 years of satisfactory service. If finances permit one motor-scooter should be provided for each major district. This should be strongly built (to cope with bush tracks) and have a secure high-backed and well-padded pillion seat suitably fitted with safety belts for sick patient carriage to and from the District Hospital or Rural Health Centre.

6.. NEW APPROACHES School extension examination room (and site for regular 'Bicyclinics').· As mentioned earlier – although few settlements are within reasonable walking distance of a rural health post, virtually every village or cluster of hamlets has a school. It is recommended that bringing these schools into the rural health service network would create lasting benefits at minimal cost.· A simple single room extension could be added to the school – using local labour and materials and having a chair, table, lockable cupboard, window and a thatched roof (if this is not possible the common practice of temporarily vacating one classroom for the regular monthly 'Bicyclinic' would be an acceptable temporary alternative).· The extension would be equipped with an inexpensive wind-up microscope with basic equipment for making and examining stained slides (blood, urine, faeces etc) and a ‘Mini-Spindoctor’ string-operated microhaematocrit centrifuge with recycleable plastic capillary tubes the small holding block and Hb(g/dl)/PCV% and Micro-ESR reader cards. · Training would be given to a suitable candidate Village Health Worker – possibly one of the brighter school-leavers interested in working in Primary Healthcare (Headmaster to choose - also see note under 4.3 above)).· When not needed for patient examination the microscope could be used to improve and extend the school science curriculum. This would serve to introduce all children to basic hygiene and healthcare matters, at an early stage when they are most impressionable, and lay a firm foundation for better self-help measures against the common diseases. The role of children in local health improvement measures is of paramount importance, since it is they who will best learn the important new health measures needed; equally important, they will guide their own children and so ensure that these better health practices prevail. Prepared by: Dr.Roy Rickman, MSc(Dist), PhD, DLSHTM, FIBiol.,FIBMS – formerly Senior WHO Scientist (working in Africa 1963 – 1984) and Senior Research Fellow, LSH&TM (1984 -1988). Em. This e-mail address is being protected from spambots, you need JavaScript enabled to view it February 2006.