What I Learned About Public Health in the Eastern DRC

Dear Blog Followers,

I did not keep my promise to you and write timely posts about my trip to the DRC. Life got busy. I also decided to take a different approach in what I'm going to post, presenting what I learned during my trip. So today I'm starting with Public Health. Eventually I also hope to write to you about the DRC, my Doctoral Research AND myself. 

As a refresher I was in the DRC working on a review of humanitarian assistance between 2006 and 2016. If this post troubles you I invite you to consider donating to MSF (specifically to their hospital in Masisi) or to Heal Africa in Goma. 

http://www.msf.ca/en/donate-now

http://www.healafrica.org/donate_to

My initial role on the review team was as the Public Health Expert, although methodological lead was later added to the list of my responsibilities. I was invited to fill this role not because of my extensive education in Public Health but because of my general experience around public health policy including the social indicators of health and helping to run the health clinic at KW Reception House. Fortunately, the review didn’t require any knowledge of the biological and epidemiological components of public health because then we would have been in trouble.

As the Public Health Expert on the team it was my job to interview individuals engaged in public health work. This included local chief medical doctors, nurses, nutritionists, project coordinators for international NGO’s and sometimes their heads of missions. I also visited numerous health centres and hospitals, camps for internally displaced people and NGOs. It was extremely eye opening.

Over at least the last 15 years most of the health centres and hospitals have been run with the support of international health partners. They are often operated by local doctors and nurses but their programs and access to medicines are funded by international partners. As a result of this support, they have been able to offer free medical assistance and medications to the local population in part and in whole. However, recently because of donor fatigue and the redirection of funds to new crises such as South Sudan many international health organisations have reduced or completely cut their assistance to health sectors across Ituri, North and South Kivu where the local population is now being asked to pay for medical assistance. This worried many of the local health care practitioners who I spoke with who indicated that much of the local population could not afford to pay the nominal fees that they were now being charged by the health centres and hospitals. This is particularly concerning because the primary causes of death in the region (malaria, respiratory infections, cholera and TB) are highly contagious but treatable illnesses. Lack of access to treatment could easily lead to the spread and possibly epidemics of these diseases resulting in a significant increase in mortality, particularly among vulnerable people including children and IDPs.

I also observed the conditions at the medical centres and hospitals. There were two examples of best practices. The first was the hospital in Masisi which we visited at the beginning of the trip. The hospital is funded by MSF and has extensive wards for malnutrition, trauma, maternity and pediatric care, it also has a well stocked pharmacy. All treatment delivered at the Masisi hospital is free. Unfortunately, the week we visited the malnutrition ward in the hospital was over flowing because desperately needed food aid wasn’t reaching its recipients because of corruption in the supply chain. The other strong example was the Heal Africa hospital in Goma. Like, the Panzi hospital in South Kivu where I visited in 2016, the Heal Africa treats and supports victims of sexual and gender based violence. The hospital is extensive and offers both medical and social services to its patients.

These two hospitals were very much the exception to what I saw. The most troubling cases I visited were health centres in Ituri, both which had recently lost funding. When I asked for a tour of the first health centre near Komanda I was shocked to see that the birthing room consisted of an examination table with a hole cut into it and a basin underneath it to catch the baby. The room was so dark, damp and dirty, I couldn’t imagine how giving birth in such a place could reduce maternal or infant mortality (although it apparently does, at least according to the statistics on their wall). The second health centre I visited in Mangiva was in much better condition and seemed to have more services available. However, that health centre had been attacked and raided by militants three times in the past three years and during the last attack the head of the centre, a young father, was briefly taken hostage.

Mangiva Health Centre

I also learned quite a bit how different diseases and socio-economic conditions can interact with each other to exacerbate existing conditions and contribute to elevated mortality. For example, someone who is chronically malnourished is more likely to die as a result of a cholera infection. People living in under-supported long-term IDP camps, without proper sanitation structures such as the one in Kalite in the Masisi territory are very likely to be affected by both. Further, when people flee fighting and war in the Eastern DRC, they also spend days and weeks hiding in forests, or walking to seek safety, where they are at much higher risk of being exposed to Malaria. Sub-standard living conditions and nutrition can also increase susceptibility to respiratory infections, as can HIV infections which is spread by the scourge of sexual and gender-based violence.

I was also exposed the complexity of sexual and gender based health in the DRC. While I was there I spoke with a counsellor at a counselling centre for victims of sexual and gender based violence who didn’t know that she could use condoms to prevent unwanted pregnancies. I also met a priest who was prepared to distribute condoms to his parishioners in order to prevent malnutrition cases being caused by women conceiving too soon after giving birth (I gave him $20 to buy condoms). Finally I learned that, an well-known international health NGO has started offering free abortions to women who need them, despite the fact that abortions are illegal in the DRC.

When I was in the first year of my Ph.D. I read an article by Marriage (2013) which argued that international health NGOs should stop providing free health care in the DRC because they were duplicating state services and preventing the government from taking full responsibility for the sector. The Congolese government is not taking responsibility for the health sector (or most other sectors) and the local population cannot afford to pay the fees associated with medical treatment in the East. Another example of this was an HIV/AIDS advocate who shared with me that while the government provides free Anti-retroviral treatment for AIDS patients they don’t cover the cost of medication for opportunistic infections which could kill them and be spread to other parts of the population. Many people in the East with HIV/AIDS are too sick or stigmatized to work and so obviously can’t afford these medications.

To conclude, a full pull-out by international medical organisations would result in an overwhelming health crisis, which is already reflected in recent cholera outbreaks which have occurred across the East. More money needs to be directed back into the DRC to ensure that the most vulnerable people continue to have access to urgently needed medical care.