I hate needles. And pills. And potions.
For the last 48 hours I’ve been obsessively measuring the growth of a blister on my throbbing left arm. I’ve been feeling sick from the tablets I received at my emergency appointment two days ago with the ‘Same-Day-Doctor’ in London, Canary Wharf. Worried and anxious, I’m now back for my results.
Thankfully, the Mantoux skin test has shown that I don’t have latent TB, my anti-malaria drugs are kicking in and I’ve had no reaction to the yellow-fever, typhoid, hepatitis A, DTP, BCG and goodness knows what else, jabs.
Preparations are progressing well for my trip to Ethiopia where I’m investigating how best to reduce Tuberculosis in some of the poorest communities in the world. TB, or consumption, is one of the top 10 causes of death worldwide. In 2015, 10.4 million people caught and 1.8 million people died from the disease.
Headlines from Ethiopia spin in my mind. LiveAid, Biblical Famine, Birth-place of Modern Humanity, endangered Gelada Baboon and Ethiopian Wolf. Bob bloody Geldof hectoring me to feed the bloody world. A swirling fog of vague recollections combine with feelings of frustration, catholic guilt and helplessness.
Arriving in Addis Ababa is like going back one hundred and fifty years to a Dickensian London of slums, child labour and consumption. With 100 million people, Ethiopia has the second largest population in Africa. A third of which earn less than $1.90 a day, many on coffee plantations providing my daily $5 coffee kick.
In Addis I’m working with a group of inspirational people and organisations trying to learn from their successes and failures in preventing and detecting Tuberculosis.
To raise awareness and counter the stigma of TB these organisations are using street theatre, social media campaigns and storylines on popular soap operas. They are supporting ex-TB sufferers in immigration camps who are choosing to wear ‘TB-Survivor’ T-Shirts and stand up in public to tell their story.
Creative approaches are being trialed to screen hard-to-reach groups. In an immigration camp, members of the Health Army have been trained to use World Health Organisation questionnaires to screen the complete population of 40,000 people. In a separate programme to support migratory communities, Health Army workers are being trained to go into the field to take sputum samples from those with persistent coughs, and to stain and fix these samples on slides for later diagnosis by medical professionals in clinics.
Sputum samples collected from hard-to-reach communities need to be tested by clinicians in hospitals and health clinics to detect whether people have TB. Through agreements negotiated by the World Health Organisation with for-profit businesses, a network of sophisticated TB diagnostic equipment and trained medical professionals is being created.
For people living in mountainous terrain, often two days away from any healthcare facilities, joint teams of volunteers, clinicians and doctors are working with local community leaders using mobile equipment to screen, take samples and test all members of a community over a small number of days. This community-based approach provides vital healthcare services where they are needed, and helps ensure the whole community takes responsibility for its collective health.
From all my discussions it’s clear that small amounts of money in the hands of passionate, dedicated people can have an immediate affect. But I want to see this for myself. I want to see whether this is scaleable and sustainable.
I’m travelling to Gonder in the northern state of Amhara, the home of the Amhara people. Tired and coughing after a long, hot, dusty journey I’m becoming slightly paranoid. When is a persistent cough persistent? Clearly now an expert, I practise my sputum collection technique ‘just in case’. Relax. Three deep breaths. A deep, hard cough. Yellow or green gooey lung sputum is best. White saliva won’t do. Forgetting for a moment my pin-cushion arm, I’m consulting Dr Google. Ok, a persistent cough needs to be for three weeks, not three days. I think I’m going to survive.
The Amhara make up twenty five percent of the population in Ethiopia and are some of the poorest people in the world. Largely pastoral, many Amhara move throughout the year from mountainous, mid-temperate to low-land terrain to ensure access to pasture land for their livestock.
Grouped into extended families of around fifty adjacent households, or Gote, male elders lead each community. By the age of eighteen, forty percent of girls have had an arranged marriage and then spend their lives looking after children, working the fields and fetching water. Divorce is illegal but widowed women – dressed in white – are allowed to remarry.
Walking through the streets of Gondar and the surrounding settlements I’m struck by the basic nature of their infrastructure. I find it difficult to understand how so many people can still be living in wood framed, mud houses with unreliable water, sanitation and power, after forty years of economic growth of over five and a half percent a year and thirty years of aid.
What is clear is that this style of living is ideal for the TB virus. When people with lung TB cough, sneeze or spit, they propel the TB germs into the air. A person needs to inhale only a few of these germs to become infected. In a population where eighty percent of people can have latent TB, close living in poorly ventilated rooms means that TB is easy to catch.
Dealing with TB in a meaningful, sustainable way therefore must also address the impact of extreme poverty. But there are no easy solutions. To improve the lives of the Amhara; government, private individuals and donors are helping fund housing, access to water, sanitation and electricity. Roads, schools and medical facilities are slowly being built. Being greeted everywhere by beaming, welcoming smiles makes it easy to romanticise this largely western approach to building communities. But of course this effectively urbanises parts of the population and in the process distances people from their pastoral traditions and social bonds. This at a time when many Western countries are experimenting with more sustainable, greener, community models.
Traditional ways of living are being strained further in Ethiopia by changes to the Amhara state boundary being made by the Ethiopian government. The government is dominated by the minority Tigray ethnic group, which since its election has been redrawing state boundaries to move fertile land from the Amhara state into the adjoining Addis and Tigray states. This forces the Amhara people into the less fertile Semien mountains, making it harder for them to grow food, generate income, and access health services, housing, roads, water, electricity and sanitation services. Flight into the mountains also speeds up the degradation of the natural environment and puts the Amhara into direct conflict with the Gelada Baboon.
Travelling into the Semien mountains I start to see some of the challenges of living in this beautiful rugged terrain.
Groups of very young children gather high in the mountains to tend cattle, sheep and goats rather than go to school. Most rural families can’t afford to send their children to school and many believe that work is simply more important. According to UNICEF, between 2002 – 2012 nearly 30% of children worked, and of those that did go to school 60% dropped out of primary education.
The degradation of the natural landscape because of extensive agriculture and mining is also clear to see.
As the Amhara people are pushed further into the mountains they in turn literally push the Gelada Baboon closer to the cliff edge. This is because the Gelada eat only leaves and grasses – the only primate graminivores – and are losing out in the battle for grazing pasture against domesticated cattle and goats. Most Gelada now stay within 2 km of the escarpment edges, where they retreat at night to sleep or if alarmed.
Gelada used to have a very wide range, including South Africa, Malawi, the Democratic Republic of the Congo, Tanzania, Uganda, Kenya, Ethiopia, Algeria, Morocco, Spain, and India. Ethiopia is now their last refuge, with numbers reducing from 800,000 to 200,000 over the last 50 years.
The Gelada live in large communities of up to 200, constantly preening, chattering and communicating. Some believe that the range of their vocalisations are close to that of humans and includes reassurance, appeasement, solicitation, ambivalence, aggression and defense.
Gelada also communicate through gestures. They display threats by flipping their upper lips back on their nostrils to display their teeth and gums, and by pulling back their scalps to display pale eyelids.
The dry season is coming to an end and very soon the mountains will be cut off, covered in cloud and torrential rain. The Gelada will remain while many of the Amhara people will move to the low-lands and urban centres. My time in Ethiopia is also coming to a close.
Back in London three weeks after my return from Ethiopia I’m watching reports of riots and killings as Ethiopia spirals into chaos. The proposed reallocation of fertile land from Amhara into the Tigray state has caused rioting amongst the Amhara community and resulted in the most violent crackdown against protesters in Sub-Saharan Africa since the Ethiopian regime killed at least 75 people during protests in the Oromia Region in November and December 2015. The Ethiopian government has announced a state of emergency for six months, the UK Foreign and Common Wealth Office is recommending only essential travel and insurance companies are withdrawing cover.
I’ve learnt that there are no simple answers. Reducing tuberculosis clearly requires addressing immediate gaps in the health care system. Addressing the fundamentals of extreme poverty is also necessary but this can’t be achieved by blindly providing Western-style infrastructure. However if inequality and weaknesses in the democratic, representative process are not also addressed there will always be a risk of instability quickly and unpredictably crashing into crisis.
Addressing these challenges is complex, messy and requires a long-term commitment. But withdrawing isn’t an answer either. As well as having a direct, catastrophic impact on the people immediately involved, the consequences of instability and crisis will continue to spill over national borders. This could be in the form of health pandemics, mass migration or the degradation of our natural environment.
Having the humility to realise that we don’t have all the answers and that we need to enable local people to drive their own change is a good starting point. Providing focused expertise and funding to support locally identified and well-defined changes is also valuable. Well-timed support from trusted people and institutions, which understand the limitations of their own power and influence can also help the political process.