Blog Posts by Fred Hartman

{Photo credit: Todd Shapera}Photo credit: Todd Shapera

In the Geita District in Tanzania’s Lake Zone, some 10 kilometers from the nearest health facility, a one-year-old girl child wakes up crying with a severe fever. “We used to walk more than 10 kilometers to present our sick children to Geita Regional Hospital,” says Joyce Bahati, the girl’s mother.

Access to proper diagnosis and medicine is critical when a child develops a severe fever. A long journey can delay treatment, or for some, discourage seeking care altogether. In rural sub-Saharan Africa, where the nearest fully-functional health facility may be, at best, a three-hour journey on foot, women and children often turn first to community-based caregivers and medicines sellers or small health dispensaries as first providers of primary health care, including severe fever.

 {Photo credit: Fred Hartman/MSH}Dr. Logan and two women Ebola survivors at Annex 3.Photo credit: Fred Hartman/MSH

Tuesday, November 4, was my first day back at MSH headquarters since returning from Liberia nearly three weeks ago on October 21. I volunteered to go to Liberia—one of three West African countries at the center of the Ebola outbreak—because MSH has a wealth of experience to offer to help resolve one of the great public health challenges of our time. 

I started my career in smallpox eradication, and through the years have worked on other outbreaks: hemorrhagic fevers, SARS, avian and pandemic influenza, and multi-drug resistant tuberculosis (TB).  These diseases were—and are—highly infectious and carry significant mortality if proper infection control procedures are not followed.

 {Photo credit: Ian Sliney/MSH.}"Let's prevent Ebola together" billboard in Liberia.Photo credit: Ian Sliney/MSH.

Management Sciences for Health (MSH) hosted an interactive, three-day, online seminar on the West African Ebola outbreak on LeaderNet.org, October 28-30, 2014. Edited summaries from seminar facilitators (MSH Global Technical Lead on Malaria and Communicable Diseases, A. Frederick Hartman, MD, MPH, Days One-Three, and co-authored by Independent Pandemic Planning Advisor, Lisa Stone, Day Two), appear below. You can access seminar archives, including resources for preparedness and response, by joining LeaderNet.org.

Day One (Oct. 28): Mobilizing community-based care

Many thanks to the 240 individuals from more than 50 countries who have signed on to participate in the LeaderNet Ebola seminar so far. I am very impressed with your interest and enthusiasm in discussing, and ultimately controlling, this massive Ebola outbreak.

"I thought I [would] go home with a dead child. I came carrying my child on my back. She was lifeless. Now my child is well and she is walking," said the mother of 5-year-old Ajak in South Sudan.

Ajak was ill with malaria, the number one cause of death in South Sudan.  Ajak and her mother had come from Nyeith village to Panthou Primary Health Care Center (PHCC) in Aweil South County, a facility supported by the MSH-led, USAID-funded Sudan Health Transformation Project (SHTP II). SHTP II focused on improving the diagnosis and treatment of malaria in that fragile state emerging from 35 years of conflict. Arriving in a coma, Ajak was admitted to the pediatric ward for further management and investigation.

The Panthou medical team immediately started Ajak on a quinine drip for a presumed malaria infection, which blood slides then confirmed. The following day Ajak remained in a coma, and her mother’s hopes for her child’s recovery were fading. In discussion with family members, Ajak's mother decided it was time to bring the sick child back home to their village.

 {Photo credit: Todd Shapera.}A Rwandan mother and newborn rest under a bed net.Photo credit: Todd Shapera.

Over one hundred years ago on this date, (August 20, 1897), British scientist Sir Ronald Ross discovered that infected female mosquitoes transmit malaria between humans. (Like any vector borne disease, the malaria-causing parasite, Plasmodium, needs a specific host: in this case, the mosquito. The female mosquito needs blood to nourish her eggs; the male just eats nectar.) Dr. Ross received the Nobel Prize for his discovery that year. Today, we mark the day, August 20, as “World Mosquito Day.”

What’s all the buzz about?

A child in sub-Saharan Africa dies every minute as a result of malaria—more than 1,400 children globally every day. Malaria affects about 220 million people, with 80 percent of all cases occurring in just 17 countries. The World Health Organization (WHO) estimates that 660,000 people died from the disease in 2010; most in Africa. Two countries—Democratic Republic of the Congo (DRC) and Nigeria—hold 40 percent of the burden of malaria mortality. Despite these challenges, progress is being made: since 2000, malaria mortality rates have dropped 33 percent in Africa, and 25 percent globally (more on malaria from WHO).

World Hepatitis Day is commemorated July 28. {Photo credit: C. Urdaneta/MSH, Afghanistan.}Photo credit: C. Urdaneta/MSH, Afghanistan.

Hepatitis is a personal disease for me.  Some years ago, I spent two weeks leading training workshops for faculty at the University of Costa Rica in San Jose, Costa Rica. The work and the participants were delightful, as we worked together to improve medicine prescribing practices. Every day I ate lunch at a local seafood restaurant, often joined by a colleague. One Friday, two weeks after returning home, I felt exhausted—so tired that I could not continue working. By Sunday I was orange as a pumpkin, unable to walk or keep food down. I visited my physician and was diagnosed with acute, severe hepatitis A. I felt like I was dying. I lost 6 weeks of work and 25 pounds before I was able to return to normal functioning. I discovered that the colleague who had joined me for lunch developed hepatitis A with the same intensity and duration, and at the same time.  We traced this “point source outbreak” to some uncooked mussels that the restaurant used in a fish sauce that transmitted the hepatitis A virus to us both.

World Malaria Day 2013 {Photo credit: UNHCR/S. Hoibak.}Photo credit: UNHCR/S. Hoibak.

To me, malaria is a very personal disease.

I first came face to face with malaria during the war of my time: Vietnam. I was plucked out of residency after my first year, with only an internship under my belt, and sent as a Navy Medical Officer to war. Medical school and residency prepared me well for much of the trauma I encountered medically, but I was totally unprepared for the large-scale emotional trauma, and for the tropical diseases I had encountered only in books.

I was overwhelmed by the young children with malaria, some of whom literally died in my arms while treating them.  Yet, I also witnessed bona fide miracles: children at death’s door, comatose and unresponsive, who responded dramatically to treatments, and ultimately went home to their families.

To address malaria, I focused on promoting prevention (long-lasting insecticidal nets [LLINS] for families and intermittent preventive treatment [IPT] for pregnant women), early detection, and early treatment in the community—what is now called community case management.

That was 40 years ago.

When I worked in Smallpox eradication in the mid-1970s, I traveled all over northern India and Bangladesh. I never took malaria prophylaxis, because malaria had been cleared from those areas. Likewise, I did not take malaria prophylaxis when I worked in the Brazilian Amazon in the late-1970s. At that time, malaria was found only in gold miners in isolated tributaries of the Amazon. Now, due to our financial inability to continue high levels of malaria eradication activities worldwide in that time period, emergence of both anti-malarial and insecticide resistance, and spread of the mosquito vectors, all of these are heavily malaria endemic areas with a high mortality rate for pregnant women and children.

The World Health Organization (WHO) recently released the World Malaria Report 2012, summarizing 2011 data from 104 malaria-endemic countries and citing progress and challenges toward the eradication of malaria.

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