Botswawa HIV update

Unu Lebakwe, Botswana Television

Thanks for your efforts of keeping me update with the latest issues pertaining to HIV/AIDS and other related health issues.

To share with you on how Botswana is doing with regard to HIV/AIDS issues; president Festus has last week told the ruling BDP women's congress that the government is proud to announce that more than 80-thousand people have enrolled in the ARVs roll out programme manned by government. The ARVs in Botswana are given out free.

Still on issues related to the scourge the research on HIV prevention vaccines, 1200 volunteers to participate on the programme.

Gambia TB situation alarming

Yusupha Bojang, Gambia

TB is one of the illness spreading due to the number of patients visiting the health center in the BRIKAMA REGION according to the TB officer in the region. The situation is alarming.

Lesotho to reduce HIV in children

by Teboho Senthebane, South Africa

The Lesotho government has launched a four-year plan to reduce new HIV infections among children by 50 percent and ensure that all HIV-infected children have access to life-prolonging antiretroviral (ARV) treatment.

Mother-to-child transmission is the leading cause of HIV infection in children. Lesotho introduced prevention of mother-to-child HIV transmission (PMTCT) services in 2003. WHO and UNICEF are partnering with Lesotho's Ministry of Health and Social Welfare to implement a new plan that includes establishing universal access to PMTCT services and reducing the risk of mother-to-child transmission by 80 percent by 2011.

TB Day: a Zambian perspective

Is there anything awry with the response to TB or has the time come to re-strategise the way TB is being tackled? Violet Mengo, features reporter with the Zambia Daily Mail, reflects on what has been achieved so far and the way forward.

Tuberculosis is one illness that has spread to all the nine provinces in Zambia and the Ministry of Health is fast extending coverage of its programme. In its shadow, drug resistance is upping the pace.

March 24, each year, is observed and recognised as World TB day, a time when humanity is challenged to reflect on the way the disease has negatively impacted on the country and the world as a whole.

In Zambia, DOTS (Directly Observed Treatment Short Course), the internationally recommended TB control strategy that includes standardised case detection, treatment and patient support that requires consistent drug supply and effective monitoring systems is in place.

Zambia has adopted and implemented DOTS since 2000. Full national DOTS coverage was reported achieved at the end of 2006 with an estimated treatment success rate of 90 per cent.

But is it really time to focus on DOTS more intensively?

According to the World Health Organisation (WHO), drug resistant TB is a symptom of poor programme performance. If we hope to change the outcome and decrease the proportion of drug resistant TB, the DOTS model needs to be adapted or its implementation improved. More of the same might only compound the TB drug resistance threat.

Despite the recent DOTS coverage gains in Zambia, many communities in the rural areas are lagging behind due to a number of reasons. Rural settings, poor communities and mobile populations, for example are subject to social and economic factors that often lead to incomplete or inappropriate treatment. In addition, TB diagnosis is difficult in people living with HIV- a growing proportion of people with TB today.

Better strategies to make TB control programmes work more effectively for the most vulnerable and hard to reach communities are also essential to improving treatment adherence and, as a consequence reducing drug resistance.

The Ministry of Health 2006 annual report highlights Multi Drug Resistant TB (MDR-TB) as having been encountered in Zambia and its presence in HIV programme.

MoH spokesperson Dr Cannisius Banda said MDR-TB has been reported in almost every part of the country. In 2005, approximately 50 cases were reported.

The ministry has worked round the clock to ensure that MDR-TB is seriously addressed through sensitisation in all parts of the country.

“We can however, have a major impact on TB today, by rapidly identifying and curing patients with active disease. This approach is at the heart of the internationally recognised strategy for TB control (DOTS) which has proven remarkably effective in Zambia,” said Dr Banda.

TB has continued to be one of the major public health problems in Zambia and is among the top ten causes of morbidity and mortality.

However, the TB notification rate has increased from about 100 per 100,000 in 1984 to 500 per 100,000 in 2005.

TB has a profoundly damaging economic impact on patients and their families through spending on diagnosis and treatment, transport to the health facilities and time lost from work. Yet the disease can be cured with drugs that cost as little as US $14 to US $18 per patient.

The interaction of TB with the human immunodeficiency virus (HIV) infection has complicated and made the TB control programme difficult. TB has become the leading cause of death among people living with HIV/AIDS in Zambia today, while infection with HIV is the most potent risk factor for a latent infection to convert to active TB.

Recently, WHO launched yet another treatment - a new stop TB strategy that has six components of which DOTS is one of them.

The adoption of the new stop TB strategy is also in line with the Global plan to stop TB, in efforts to achieve the targets for the Millennium Development Goals (MDGs) by the year 2015.

The main objective of the TB programme is to reduce morbidity and mortality and socio-economic burden associated with the disease, therefore reducing the public health importance of TB. The new stop TB was planned for implementation in all districts countrywide in 2005.

In the same year (2005), international and local cooperation partners conducted a national TB Review. The findings and recommendations from the National Review formed part of the basis on which the National TB strategic plan was developed. The priority areas that the plan has addressed are:

- TB DOTS expansion and strengthening

- TB/HIV collaborative activities

- Community DOTS strengthening

- Public-Private Partnerships

- Health systems strengthening

- Health promotions

TB control programme aims at reducing the prevalence of and deaths by 50 per cent and eliminating the disease as a public health problem by 2050.

The control programme also targets to detect at least 70 per cent of the infectious TB cases and cure as least 85 per cent of them, to meet Millennium Development Goal (MDG) number 8 of stopping and beginning to reverse the incidence of TB by 2015.

Dr Banda expressed happiness at the pace the ministry was moving in addressing TB and the achievements scored so far.

He said there has been expansion in TB support visits that were carried out while the DOTS programme was expanded and strengthened.

A national TB/HIV coordination team was formed and health workers and community treatment supporters were trained countrywide.

The fight against TB can be won if the country had a good number of health staff. But the brain drain has hit the country badly that capacity building for the national TB control programme is limited.

The central unit has only two out of the five required staff establishment. There is high attrition of trained staff in the Ministry of Health (MoH) yet the workers’ manual has not been revised.

There is low HIV testing of TB patients despite a co infectivity rate of up to 70 per cent. The MoH says the patients are not counselled and tested for HIV infection so that they can be helped with drugs at early stages.

The 2006 annual reports says inadequate nutrition supplement for the TB/HIV/AIDS is high because many people in Zambia live below the poverty levels.

About 70 per cent of people living with TB are co-infected with HIV and this makes the fight rather difficult.

The enormity of the TB burden requires that TB diagnosis and treatment be taken beyond the health sector. The existing umbrella body for community-based organisations involved in TB control (Community Based TB Action Group- COBTAG) is limited and needs strengthening. The existing structures in Zambia for home-based care provide an opportunity to encourage communities to participate in TB and TB/AIDS activities.

Advocacy, Communication and socio (ACS) mobilisation has continued to be one of the weak components of the National Tuberculosis programme and needs to be prioritised.

Responding to the challenges of drug resistance and TB in general will require rebuilding the basics of the programme in a number of ways. Training and retaining health workers in sufficient numbers, strengthening diagnosis and laboratory facilities, maintaining continuous drug supplies (including second line drugs for treating drug resistant forms of TB would be essential in combating MDR-TB.

Gambian President boasts HIV/AIDS cure

by Amadou Bah, Assistant Producer, Gambia Radio and Television Services, Banjul

The President of the republic of The Gambia, Alhaji Yahya Jammeh, on Wednesday, January 17, 2007, announced his decision to treat Gambians living HIV/AIDS and Asthma sufferers in the country. In his speech, at the state house, President Jammeh disclosed that he now has authorisation to treat HIV/AIDS and Asthma patients.

In fulfillment of his promise, today, President Jammeh administered treatment to the first batch of HIV/AIDS patients at State House. The President was assisted by a team of medical personnel during the morning session.

Defending his new "mandate", Dr. Jammeh pointed out that his patients must first be diagnosed as HIV positive and should then consent to be treated publicly.

He said his treatment would last only for few days, after which, the patient should go back to the hospital for a further test to re-confirm his or her status. The President also said he is mandated to carry out his treatment only on Thursdays and he will limited to ten patients at a time.

Commenting on the treatment of Asthma, President Jammeh said he is "mandated" to treat one hundred patients at a time, under strict conditions.

In her speech, the Vice President Dr. Aja Isatou Njie Saidy applauded President Jammeh for the initiative, describing the intervention as very timely.

Cameroon journalist reports on South Africa

by Ngehndab Delphine, Cameroon In November, 2006, I was in South Africa on an environmental reporting course sponsored by the Reuters Foundation . I thought it necessary to send you some of the pictures I took in Kliptown, one of the oldest settlements in Soweto. We visited Kliptown wetland where we found barefoot children play next to a stream of raw sewage that slowly trickles down to the river. It is school hour and the children in their innocence are playing around the filthy area so happy yet very unaware of the health hazards the environment poses to them and their community as a whole. A repugnant stench from rotting waste fills the air. The area is littered with use papers and plastics that only go a long way to prevent the wetland from purifying the water that could be used by the inhabitants of the area. A few meters away, a group of pigs are grazing on the edge of the polluted wetland. Downstream, ritual baptisms often take place using the same dirty water of the heavily polluted Klip river. This is an unlikely site if a community based conservation project based in Kliptown Operation Mayibuye, which means ‘Take Back’ was one of the main pillars of the apartheid struggle and also the operation that led to the arrest of Nelson Mandela. Now not far from freedom square, which celebrates South Africa’s new, found freedom, a new operation Mayibuye’ is taking place-also to take back or restore. But this operation has a distinct environmental flavour. It is aimed at restoring Soweto’s wetlands, including historical Kliptowns wetlands and neighbouring shanty town to its original sate of 50 years ago where the Freedom Charter was signed. Members of the Mayibuye Wetland Project have an uphill task of restoring the area.

Sickle Cell Disease Association 34th Convention

by Lukiah and Abudallah Mulumba, founders, uganda-american sickle cell rescue fund, USA

The 34th Annual Convention of sickle cell organized by the Sickle Cell Disease Association of America ended on Saturday September, 31st 2006 on a promising note. The convention which started on the 27th of September drew thousands of member organizations from across the United States, leading researchers in the sickle cell disease and physicians plus professors from across the world. Many stake holders from all over the world such as India, Nigeria, Zimbabwe, and Mali also attended. The convention was held at Hyatt Regency Dallas Reunion, Texas.
Iron overload

Some of the most promising presentation was presented by Dr. Whitley on iron overload in sickle patients. One of the most underlying complications of the disease is the development of stroke due to vasoconstriction of critical blood vessels that supply the brain with oxygen and nutrients. Studies done concluded that monthly transfusion of these patients indefinitely will reduce these strokes. On the other hand, however, there is evidence that patients who are transfused frequently do end up with iron overload since the amount of iron taken in is excreted by the body in the same amount. This iron overload causes other major complications including congestive heart failure, liver problems, and kidney problems.

Treatment of iron overload
Until recently the only available medications to help in the excretion of this excess iron otherwise known as cheleters was a cumbersome effort which could only be delivered subcutaneously through a pump because the half life of the medicine was only 20 minutes and so there was a need for continuous delivery of the medication. On a good note, oral cheletors by the names of exjade and deferoxamine have been developed. Such new techniques of treating sickle cell complications are very important to be used in developing countries with higher incidence of sickle cell disease such as Uganda. For example, using a Transducer Cranial Doppler (TCD) in many sickle cell children enables physicians to identify patients who are at risk of developing strokes in time for interventions. Jell is applied around the child’s facial area above the eye brows and the screen would be taking pictures and numbers of which the neurologist physician bases the finding.

Another important aspect of this convention was the call by many presenters that it is time to change the management of sickle cell disease by looking at the transition of sickle cell disease children to adulthood. Better management techniques have greatly reduced the level of mortality in children with sickle cell disease. Yet no efforts have been made to direct a smooth transition to adulthood and yet sickle cell disease management in adulthood continue to be neglected. There was therefore a call to come out with strategies of managing the disease in adults. In case of the United States, many adult patients find themselves unable to secure medical insurance since they lose most of the available free medical care offered by most of the states by the age of 21 years. Frequent crises also means frequent visits to hospitals with hostile care providers who look at the patients as drug seekers!! Management in childhood is always a teamwork comprised of hematologists, registered nurses, nurse practitioners, social workers, psychologists, and lab technicians. This team gets used in giving primary care to the patient until adulthood (teen age, which is 18 years in the United States). Unfortunately there is no such approach in sickle cell disease management once patients reach their adulthood. Patients find themselves being seen by multiple physicians some of whom know little or nothing on sickle cell disease. The bond and trust that had been built (for 18 years) during the early years between the therapy team and the patient is therefore broken during adulthood. Calls for smooth transition are just timely.

We do know that this kind of problem does exist in Uganda today and that there exist minimal number of hematologists specifically trained to deal with sickle cell disease adult patients. I hope that Uganda do learn from the new experience of treatment strategies for adult sickle cell patients.

Genetics
During the conference there was significant contributions made by doctor and Professor Betty S. Pace of the Department of Molecular and Cell Biology and Director of sickle cell disease research center at the University of Texas in Dallas. Professor Pace shed some light at how far researchers for sickle cell disease are in finding a cure basing on the information available from the Genome Project. The Gnome Project was completed in 2003 and it is basically a blue print of human body having been able to identify all the necessary genetic information regarding humans. Researchers in sickle cell disease just like in other incurable diseases continue to have high hopes in manipulating DNA of patients to cure diseases. It was quite refreshing to note that the National Institute of Health (NIH), which is the leading research umbrella in the health sector in the United States, is collaborating with other countries including developing countries in the search for cures of different diseases including sickle cell disease. Uganda can explore such opportunities that exist with sickle cell disease. We mentioned to Doctor Pace about our plans of starting such educational sickle cell disease conventions in Uganda, she immediately volunteered sponsor her trip (ticket, lodging etc) with others to join us in Uganda.

DNA
Another current on going research was presented by Doctor Mathew Porteus, PhD. His lab is currently trying to fix the mutation that causes sickle cell disease. The field of gene therapy developed as a way to treat genetic diseases, such as sickle cell disease, by changing the DNA of the cell for therapeutic benefit. Doctor Porteus said that, there are a number of different approaches to gene therapy, but his lab has focused on trying to “fix’ the mutation that causes sickle cell disease. His goal is to remove the blood stem cells that contain the sickle cell mutation in both copies of the b-globin gene from a patient, fix one of both of the genes so that they no longer have the sickle mutation, and then return those cells back to the same patient. He hopes that by “repairing” the sickle cell mutation in enough of the patient’s blood stream cells that he and his team can cure the disease. He was very impressed so far and discussed his progress towards this long-term goal. It may take 5 to 10 years. We are keeping our fingers crossed!!!!!!!

Nigerian experience
We were so thrilled about the support from our sister countries Nigeria and Ghana in relation to the struggle of sickle cell disease in Africa. Doctor Ramesh C. Pandey of Xechem, Inc, New Brunswick, New Jersey, presented about the new anti-sickling natural herbal drug Nicosan / Hemoxintm in Nigeria. Various basic and clinical studies of Nicosan formerly known as Niprisan have been performed over the past 10 years in Nigeria at the National Institute for Pharmaceutical Research and Development (NIPRD) and for over five years at several laboratories in the United States. Dr. Pandey was hired directly from the United States by the Nigerian government to take part in this research. He has been involved in research of this drug for a period of over five years. Nicosan is an extract of four plants which has been used by traditional health providers in Nigeria. Phase I/II clinical trials showed a decrease in the frequency of painful episodes and an increase in school attendance of people with sickle cell disease. Laboratory work carried out at the NIH NHLBI Sickle Cell Disease Reference Laboratory at The children’s Hospital of Philadelphia in United States (SCDRL-CHOP) showed that NICOSAN has strong anti-sickling effect. Their studies in vivo using transgenic sickle mice that express human sickle cell hemoglobin showed that NICOSAN not only decreased the formation of sickled cells in blood, but also prolonged the survival period of mice that had been exposed to severe hypoxia (5% oxygen / 95% nitrogen). Other studies performed at Xechem Laboratories in New Brunswick, New Jersey in United States and Xechem Nigeria in conjunction with SCDRL-CHOP have shown that NICOSAN contains various aromatic aldehydes that combine with sickle hemoglobin and inhibit sickling erythrocytes at very low concentrations. Further studies showed that NICOSAN contains chemicals that inhibit cell sickling by hydrating sickle erythrocytes. According to Doctor Pandey, NICOSAN is a new effective anti-sickling natural herbal drug available in Nigeria. The studies conducted in Nigeria, will be repeated in the United States so that it can be available over the counter by patients of sickle cell disease. We are very happy for Nigerians. Some patients/parents etc have been contacting loved ones in Nigeria to send them NICOSAN to United States.

Hydroxyurea
Currently hydroxyurea continues to have more success in treating painful events. Clinical trials conducted in 1995 showed a 44% decrease in medical contact for treatment of painful crisis. Whereas, hydroxyurea was thought to work better due to toxicity concerns, the HUG_KIDS trial demonstrated that children from five years and older could also be given the same dose basing on body weight and experience the same benefits. During the convention proceeding, there were testimonies from patients using hydroxyurea on its efficacy. While speaking about sickle cell disease in Uganda, we were told that hydroxyurea is not available at the Ugandan market and that they only read about it despite the fact that it has been on the market in the United States for over ten years now!

Bone marrow
Bone marrow transplant is still the only documented cure for sickle cell disease. Its limited use can be explained from the many problems associated with it such as finding a matching donor, surviving chemotherapy, and finding enough stems cells for therapy. The later is made easier for patients who are lucky to find a matching donor from cord blood stem cells.

HIV/AIDS & Cancer Palliative Care

by Bamuturaki Musinguzi, Kampala, Uganda (June, 2006)

Nurse Jerith, a CPCC Nurse, shows a patient and family how to measure out liquid morphine.

For a price of two or three loafs of bread cancer and HIV/Aids patients in Africa can now afford cheap pain killers for a week after the continent obtained affordable oral morphine in 1990, which can be used in a home and controlled by the sick.

This also followed the international community declaring “to be free of pain” a human right. This

brought up a challenge for medical and health workers to manage and control pain and give palliative care (a holistic approach looking at the spiritual, physical, social, cultural and economic) of HIV/Aids and cancer patients. It costs Hospice Uganda Ushs. 20,350 ($11) per week to care for a patient. Hospice asks the patients for a contribution of Ushs. 5,000 ($2.7) per week towards the cost of medicines, and less than 1/3 of its patients can afford this. It assists 60 per cent of those who cannot afford.

“It was a big break through because it’s now cheaper to bring in the morphine powder and make it here in a pharmacy,” said Dr. Anne Merriman, director of policy and international programmes, Hospice Africa Uganda.

“ If to be free of pain,’ is a human right then people should ask their MPs to have this service in their constituencies,” Dr. Merriman suggested.

“Its difficult to abuse oral morphine, there is no addiction or diversion compared to the tablets,” Dr. Merriman said.

“When taken by month it dose not give ‘a high’ if you have pain.” According to Dr. Merriman the pain of cancer never goes until one dies:

“We can control the pain of cancer of 98 per cent of the patients we treat and have the pain controlled. For HIV/Aids patients they usually get severe pain from infections such as Kaposi’s sarcoma (commonly called Kisipi in Uganda). If they have access to the antibiotics/fungi then as the infection is cured then we can withdraw the pain killers.” Dr. Merriman, who was the first director of the Nairobi Hospice in 1990 and later left to start a model Hospice in Uganda in 1993 where other countries would learn by taking care of the African cultural and economic aspects, believes making palliative care affordable has been Hospice Africa’s greatest objective on the continent.

Hospice Uganda is the model Hospice for Hospice Africa. Hospice Africa was founded in 1993, to promote the initiation of Hospice in those countries in Africa who have not yet got assistance of palliative medicine.

Uganda was the third country to commence palliative care in sub-Saharan Africa (excluding South Africa). Zimbabwe was the first (1977) and Nairobi Hospice the second (1990). The objectives of Hospice Africa are to provide and promote a palliative care service to patients and families, within a 20 kilometer radius of Hospice. To carry out education programmes in palliative medicine, to health professionals at undergraduate and postgraduate levels throughout Uganda so that this form of care can be available to all in need. It also encourages the initiation or consolidation of palliative care in other African countries, by providing a facility at hospice Uganda fro training, and experience of palliative care working in the African context.

Each year Hospice Africa Uganda has a Palliative Care Week to promote palliative care and to let people know that they have a human right to be free of pain before they die. This years week from May 8 -13th, 2006 under the theme, “We want to see that this Medical Specialty Come to Your Home,” climaxed with a hospice sponsored charity walk on May 13th from the Constitution Square in the capital city and finishing at the hospice headquarters in Makindye a suburb of Kampala to raise money for the terminally ill patients in Uganda. Hospice Uganda is entirely dependent on the goodwill of donors. In UK support comes from two charity shops in Liverpool and Ainsdale, run by volunteers. Donations come from other organizations and individuals all over the world on an ad hoc basis. WHO in 1996 recommended that nurses would be allowed to prescribe morphine in countries where there are insufficient doctors.

Uganda is the only country in the world where nurses and clinical officers have undergone training at Hospice Africa Uganda in palliative care. They can prescribe morphine without a doctor after the Ugandan government amended the law. Hospice Africa Uganda has trained over 2,730 health and non-health professionals in 21 districts of the country of which 325 are community volunteers. Hospice Africa Uganda that started with three staff in 1993 has now grown to 107 workers in three Hospice centers in Kampala, Hoima and Mbarara districts. In the last 13 years it has looked after 9,000 patients 6,000 of whom have been on oral morphine. It’s estimated that up to 60 per cent of its cancer patients also have Aids. With the conquering of infections diseases by improved sanitation and the recent arrival of Aids with its associated cancers, the causes of death are now changing. In those countries without disasters of war or famine, cancer is the first or second cause of death. Unfortunately less than 10 per cent of resources committed to cancer control are available to patients in the developing world where the biggest increase in cancer is taking place.

Hospice Africa says: Patients seek medical care with already advanced cancers and with severe consequences of pain, symptoms and gross disfigurement. Most are sent home from conventional medical establishments and clinics with few simple analgesics at eh most, as there is nothing left to be done fro them. “This leads to untold suffering for the patients and family.”

Currently in Uganda 1.5 per cent of its total population develops cancer each year. The raise from 1 per cent is due to Aids associated cancers in Uganda. Hospice Uganda looks after cancer and or HIV/Aids patients by bringing the modern methods of pain and symptom control.

“Aids has brought an epidemic of death and increased the urgency fro palliative care services not only in hospitals but in the community and reaching to village level where up to 57 per cent of the population may never see a health professional,” Hospice Africa says. “Palliative care must reach these people through training of health and non health professionals who live in the villages. 20-50 per cent of patients with HIV/Aids have severe pain. Aids has brought a great increase in cancers and Kaposi’s sarcoma is now the highest occurring cancer in Uganda.”

There is much attention given to the procurement of ARVs for Africa at present, Hospice Africa observes. “However this will not mean there is no need for palliative care for all, even those who are rich or powerful enough to access them will need palliative care when their time comes.”

Conference in Uganda defines importance of Oral Health

by Pius Sawa Murefu, Kampala, Uganda (6 june 2006)

"Oral health in the developing world is at its worst", says Dr. Shewine Shinne, president of Smile Foundation in the US, who was speaking at a health conference in Uganda recently. She also pointed out that there is now a need for dentists in these areas to be equipped with more knowledge and skills.

The conference underlined the relationship between general health and oral hygiene. A team of students and a professor from the University of British Columbia presented their research concluding that poor oral health can increase the risk of heart disease, diabetes and premature labor.

It was also noted that oral health in relation to HIV/AIDS has rarely been mentioned. Dr. Mulubya Gordwin at Uganda's Mulago hospital, says the oral cavity is the first site in which symptoms of HIV/AIDS become present. He explained that oral manifestations of HIV infection are a fundamental component of disease progression and occur in approximately 30-80 percent of the affected patient population. Symptoms such as Candiasis, leukemia, HIV gingivitis, periodontitis and ulcers are common to those who are HIV positive.

The conference, entitled, "Epidemiology, Impact Challenges and Management of Oral Health in Developing World" was held in Kampala between 5th and 6th June.

Reproductive Health Care: A Basic Human Right

by Rafiqul Islam Azad, Bangladesh "Madam we have come again today. For, my wife has conceived again—a fourth time. We have already two children and we are not in a position to have the third. Last time, her M.R. was done in July last under your care but after that her menstruation became irregular. And we failed to notice it. As a result, we became careless in using contraceptive.” This is what a Senior Assistant Secretary of the government was telling to Hasina Muqtadir, a Senior Counsellor working at the Reproductive Health Services Trainings & Education Programme (RH STEP) located at the 2nd floor of Dhaka Medical College Hospital (DMCH) a couple of weeks ago. “Ok, I am taking care of her case,” the Counsellor assured the man, a resident of Mugdapara area in the city. Being assured by the Counsellor of taking proper care of his wife, the man left for his office leaving the wife at her care saying, “I am coming back at noon.” This was the conversation between the two that was heard by this Correspondent at about 9:45am on a Sunday last month while waiting for talks with the said Counsellor on the activities of the RH STEP. After few minutes, another woman came to the Counsellor from Arihajar upazila of Narayanganj district for her follow-up treatment. The woman, a mother of four daughters and one son, had earlier done her Pep’s Smear test in the center on July 12 last year and she received treatment as she was suffering from severe inflammation found in the test. “Though I feel comparatively better than previous time but I have still some complications,” the woman, aged about 40, told the Counsellor, who advised her to continue the treatment. It may be noted that the government began a special project namely Menstruation Regulation Training and Service Programme (MRTSP) in 1989 to promote the reproductive health. Later on, the project turned into an NGO called as RH STEP in October 1983. The RH STEP now is playing a complementary role to support and supplement in consonance with the GoB’s national health programme targets in reducing maternal mortality rate and morbidity and other reproductive health hazards in Bangladesh. Not only government officials or housewives, Hasina Muqtadir said, women and adult girls from all walks of life come to the RH STEP everyday with their various problems relating to the reproductive health and for treatment and counselling. “The clients are given counseling first. If the counseling is of not considered sufficient to heal their complains, then other actions are also taken as deemed fit for,” she said. Sometimes, the Counsellor said, “We have to do M.R for street girls and unexpected pregnancies of adolescent girls who are victimised socially considering the human ground.” “Everyday 10 to 15 patients are being attended by us,” she said adding that for a single case of M.R an amount of Tk 120 to Tk 130 is charged for. However, if the case is complicated one, the amount may rise to Tk 500. “Most of the women generally come to the RH STEP for M.R. Besides, Pep’s Smear, pregnancy test and such tests that are necessary are done here. When the women leave the center, they are provided with health education and contraceptive pills,” said the Counsellor adding that treatment for uterus infection, which is found common among the mothers or women of child bearing ages are also given to them. A total of 18 RH STEP centers, mostly located at the government hospitals attached with medical colleges and major district hospitals, have been working from 1983 to facilitate the reproductive health care in the country. The RH STEP, funded by the Swedish International Development Agency (SIDA), is engaged in an unabated fight to reduce the maternal morbidity and mortality rate due to induced and septic abortion by providing M.R training to doctors, FWVs, paramedics, nurses etc. It has been providing M.R and contraceptive services besides counselling to M.R clients for follow-up visits, the Executive Director, Quazi Suraiya Sultana said. According to its annual report, the RH STEP has performed over 58 thousands M.R cases during the last fiscal year when about 63 thousands pregnant women were counseled during the period. Of them, maximum clients (28%) are of 25 to 29 age group who were provided the M.R services while only 5.20% clients of 40 and above age group were in the minimum level. The percentage of M.R recipients of 20 or below age group were 5.44. Of the M.R recipients, highest number of 17,160 women with two children were provided the service. At the same time, contraceptive M.R training was imparted to 782 persons including, government and private doctors, FWVs, paramedics, nurses and medical assistants. The report shows that contraceptive services were extended to 68 thousands women and girls when 8,926 patients were given treatment after pep’s smear test during the period. Besides, the RH STEP also provided antenatal care, post-natal care, family planning and other services to more than 20 thousands clients. In addition to the initiative, all the government medical college hospitals, districts hospitals, specialised hospitals, Upazila and Union Parishad level health complexes and thousands of health workers across the country have been providing the reproductive health services. Health experts say there are excellent GO-NGO infrastructure across the country in providing the reproductive health but many of them alleged that most of those remained unutilized due to inadequate supply of medicines by the government and also non-availability of funds. Sources said significant awareness has already been created among the people due to the GO and NGO effort but there are still 30 to 40 per cent women and adult girls in the country who remain unaware of the reproductive health issues. Sources said maternal mortality rate has significantly been reduced to 3 per cent per thousand from the 6 per cent of the seventies. The institutional delivery is also increasing day by day, sources said, it has now stood at 11 per cent with one per cent enhancement than that of last year to reduce child and maternal mortality rate. According to sources in the Family Planning Directorate, about 23 thousand family welfare assistants and 15 thousand health assistants are working at the grass root level for providing basic health and family planning service delivery. About 30,000 “satellite clinics” are also organised at ward and community levels every month all over the country aiming to bring the service facilities at the door step of the people. In that package we deliver antenatal care, family planning, health education and EPI services, said a highly placed official of the directorate. MA Akmall Hossain Azad, Director General of Family Planning Directorate, said that under the directorate reproductive health service and education are being given from its 80 maternal and child welfare centers across the country. On average some 5,000 safe deliveries are being conducted from the centers in each month, he said. Besides, about 3,500 Family Welfare Centers are also proving reproductive health services including free distribution of contraceptives, the DG said. Of the specialised government hospitals, Azimpur Maternity Hospital provides all sorts of maternal services including safe delivery and counselling to the mothers and adolescents. Dr Md Ziaul Karim, Superintendent of the hospital said around 500 expecting mothers come to the hospital for taking health services. He added that over 500 delivery cases are conducted at the hospital in each month. Of them, about two-third are being conducted by Scissorian section operation as most of the complicated cases are referred to this hospital for its reputation. The Urban Primary Health Care (UPHC) Project, assisted by the Dhaka City Corporation, also provides reproductive and general health services to urban people through its 38 centres in the city. There are also many NGOs, which have been working in the field of reproductive health care along with the government initiative. Of them about 15 leading NGOs are specially dealing with the reproductive health. Different GOs and NGOs like the RH STEP are implementing “Behaviour Change Community (BCC) activity to promote the awareness, particularly among the adolescents about the reproductive health so that they could protect themselves from deadly diseases like HIV/AIDS and STDs. Under the Reproductive Health Initiative for Youth in Asia (RHIYA) project funded by EU and UNFPA, five leading NGOs—Concerned Women for Family Development (CWFD), Family Planning Associations of Bangladesh (FPAB), Marie Stops Clinics Society, Bangladesh Red-Crescent Society and Save the Children UK— are also working with the adolescents. Some NGOs, notably BRAC, has a programme on sex education. Many NGOs have already developed culturally appropriate IEC materials regarding the issues for their campaign.