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MedicalJournal ofTherapeuticsAfricaVolume 3 Number 3 March 2009

KNOWLEDGE • COMMUNICATION • HEALTH

Children in school in Osun State Nigeria. Photo courtesy Stanley L Straughter.

PUBLISHERSEmerald Pademelon Press LLC

EDITOR-IN-CHIEFWA Waruingi BSc(Hons), PhD

MANAGING EDITORSA Reinhart MS

L Sulaimon Arounfale MS

EDITORIAL BOARDRD Bartucci DO

K Dabas BPharm, MBA, MSNB Datyner BE, PhD

A Ekundayo PhDKH Golebowski

A Guantai BPharm, PhDND Ifudu BPharm, PhD

HAB Increase-Coker BPharm, PhDA Inyang PhD

D Kulkarni PharmD, JDM Lwenya BPharm, RPh

TJ Lisinski PhD, MSL McFerran

A McIntosh BSc (Hons), PhDM Norton

OK Oyenuga BPharm, RPh, PhDAZ Dodgson Pekala MS

CD Pitts IV PharmDS Ray

MS Rudman MDG Sowunmi PharmD

S Sundaram PhDTW Teketel MDR Verret PhD

S Viswanathan BPharm, MSTM Zydowsky, Ph.D.

NATIONAL ACCOUNTS REPRESENTATIVEMedical Journal of Therapeutics Africa

GRAPHIC DESIGNWA Waruingi BSc(Hons), PhD

COMPOSITIONEmerald Pademelon Press, LLC

Medical Journal of Therapeutics Africa is a profes-sional medical journal. Its mission is to facilitatecommunication between the pharmaceutical indus-tries in the United States and the 53 countries ofAfrica to lengthen the lives of humans in Africa.

We select articles for publication on scientific merit,relevance to the issue focus, and contribution to theongoing dialog between pharmaceutical industryprofessionals in the United States and Africa. Noarticles are product endorsements or advertise-

ments. All advertisements will be clearly marked asadvertisements.

Authors’ opinions are their own and may not be theopinions of the Medical Journal of TherapeuticsAfrica, its editorial board, its publishing board, itseditors or its advertisers. Medical Journal ofTherapeutics Africa, its publishing board, editors,editorial board and advertisers assume no liability orresponsibility for claims, actions or damages result-ing from the publishing of any article.

AUTHOR INFORMATION. Authors retain copyrightfor their articles, so permission to print, copy orreprint individual articles or parts of an article mustbe obtained from the author. Submit articles to theManaging Editors at [email protected].

Medical Journal of Therapeutics Africa is published12 times a year by Emerald Pademelon Press, LLC,PO Box 381, Haddonfield, New Jersey 08033.

Edited and typeset in the USA. Medical Journal ofTherapeutics Africa is published as a pdf which isdisseminated by e-mail and is additionally accessedat http://mjota.org and other sites.

Contents of the Medical Journal of TherapeuticsAfrica are protected by the US Copyright Laws.Reproduction, photocopying, storage or transmis-sion by magnetic or electronic means is strictly pro-hibited by law. ISSN 1934-3507.

CLASSIFIED ADVERTISEMENTS AND SPONSOR-SHIPS: MJoTA, Ms Adore, PO Box 381, Haddonfield,New Jersey 08033, [email protected].

MJoTA VIDEO AND AUDIO STUDIOS: Contact ChiefLookman Sulaimon MS, [email protected].

MJoTA FINANCE TEAM: Contact Prof Waruingi,[email protected].

Medical Journal of Therapeutics AfricaVolume 3 Number 3 March 2009

KNOWLEDGE • COMMUNICATION • HEALTH

Ghanaian musicians celebrate GhanaianIndependence Day with Chief Lookman Sulaimon.


Instructions to authorsFor consideration by the Editors and the Editorialboard, all manuscripts must be written according tothe uniform requirements for manuscripts submittedto biomedical journals, which are posted onwww.icmje.org. We also adhere to the EditorialPolicy Statements prepared by the Council ofScience Editors (CSE) at http://www.councilscienceeditors.org/services/draft_approved.cfm.

Our style and editing guidelines can be obtainedfrom the Editor-in-Chief. In brief, add only 1 spacebetween sentences, number the references sequen-tially in the text and list the references in the samestyle as PubMed.

The preferred manner of submission is as an attach-ment on an e-mail, with pictures of figures andtables sent camera-ready as high resolution jpg files.Under special circumstances, manuscripts will beaccepted by posted mail or fax.

We accept letters, literature review articles and dataarticles giving original research, and magazine arti-cles telling stories. Articles should generally haveunder 3,000 words.

Original data articles need to be in the form Abstract(200 words maximum), Introduction, Methods,Results, Discussion.

Magazine articles are narratives and have no pro-scribed structure; accompanying photographs areencouraged. They may be as short as 200 words oras long as 10,000 words, however, they must befocused and tightly written.

We do not pay for medical journal articles or formagazine articles. You will retain the copyright foryour journal or magazine article when you assign tous rights to publish your article in an issue of MedicalJournal of Therapeutics Africa.

Each journal and magazine article is reviewed by atleast 2 members of the editorial board and the edi-tor-in-chief, and outside reviewers as the need aris-es. We adhere to the requirement of the NationalLibrary of Medicine for inclusion of journals in theirdatabase is that “neither the advertising content norcommercial sponsorship should raise questionsabout the objectivity of the published material.”

All articles published meet the standards of the

National Library of Medicine. Our major criteria forselecting each article are scientific merit, relevanceto our target audience quality of writing, and rele-vance to the focus of the issue.

We invite submission of articles reporting any dataor information that will nurture the dialog betweenpharmaceutical industry professionals in Africa andthe United States. These articles will include clinicaland preclinical studies, reviews of current clinicaland preclinical studies, discussion of devices andmedications, case reports.

Submissions of review articles and case reports mustbe preceded by communication with the Editor-in-Chief. We also invite submission of letters to theEditor, which should address observations in clinicalpractice, early results of studies, discussion of appli-cations of basic research to clinical practice or dis-cussion of clinical guidelines.

We will only accept for submission for considerationby the Editorial Board articles sent as attachments toe-mail letters. Please first send an e-mail with acover letter, then send a second e-mail with the arti-cle attached. We will only consider manuscripts pre-pared in Microsoft Word or equivalent word-process-ing program.

When we accept the article for review, we will e-mailyou and you need to reply, stating that you are thesenior author of the article under review and that alltables and figures are either original or you haveproof that you are permitted to reproduce them. Wepublish the final edited, reviewed article after youhave reviewed the proofs and given us to publish itin Medical Journal of Therapeutics Africa in whatev-er format we choose.

Send articles to Editors, [email protected]


Table of ContentsCover 70Masthead 71Instructions to Authors 72Table of Contents 73Information without bordersAldo Ceccarelli. Free software for African hospitals 74Health from wealthWA Waruingi BSc(Hons), PhD. Remittances. 76Healthcare in Africa Richard Mandell MA, Lic.Ac.The PanAfrican Acupuncture Project (PAAP) 78Centers for Disease ControlSohini Vathada MD. Malaria: current trends in diagnosis and treatment. 81The Clean ShopFhauwni Trevor Mulaudzi. We clean school toilets to keep children in school. 83

Daily UpdatesWA Waruingi BSc(Hons), PhD. February 2008. 87

BiologicsMJoTA Editors. Recombinant Human Antithrombin 95

MJoTA Publisher and Chief Lookman Sulaimon MS,at the United Nations celebrating GhanaianIndependence Day with the Ghanaian Ambassador(left, blue tie) and other African Ambassadors.

Free software for African hospitalsFor 4 years, Informatici Senza Frontiere has beenactive in Africa, mainly in Uganda and Kenya, aim-ing to reduce the digital divide.The first project was launched in 2005. The organi-zation has been working on developing useful soft-ware for hospitals, additionally installing hardwarecomponents and giving assistance during use.Also, Informatici Senza Frontiere volunteers teachand train local operators to make them autonomousin the use of the information technology.Open Hospital was the first software the organiza-tion developed and installed in several African hos-pitals, of which the first was Angal Hospital inUganda. This software assists in different funda-mental operations of hospital management. Theseinclude registration of patients, management ofexaminations and laboratory analyses, and hospitalpharmacy management.Open Hospital is an open-source software, written inJava, curently supported on Windows and Linuxoperating systems; also, it is available both inEnglish and in French.The software has been launched in more hospitals,enabling developers to improve it through userfeedback.In early 2009 the third version of the software wasreleased, and installed in hospitals in Uganda,Kenya, Benin, Afghanistan where it has been provento be reliable and user friendly. Its manual is onlineat http://downloads.sourceforge.net/angal/user-manualbeta22.doc?use_mirror=puzzle.After they install software, Informatici SenzaFrontiere volunteers travel to the hospitals to trainlocal personnel and make additional trips to monitorand support client use.Claudio Tancini, Informatici Senza Frontiere volun-teer, returned from the last mission in Angal, Ugandaduring 2008. He says: "I convinced myself evenmore deeply of the importance of information tech-nology and of our work; there still are some areaswhere our intervention could help to improve the sit-

Page 74 Volume 3, Number 3 2009 Medical Journal of Therapeutics Africa

INFORMATION WITHOUT BORDERS

[email protected] http://mjota.org

"The international community should takethe necessary steps to ensure that the poor-est countries of the world have full access toinformation and communication technolo-gies. Our objective is to connect all villagesof the world to the Internet. Only this waywe will have a digital democracy."Kofi Annan, UN Secretary-General, at theWorld Summit on the Information SocietyTunis, 16 Nov 2005

“Angal Hospital is in rural Uganda. It has a catch-ment area of about 120,000 people and has 280beds, a laboratory for chemical and microbiologi-cal analyses, a radiology ward, an operating roomand a centre for the treatment of child malnutri-tion.“Amici di Angal" association (www.amicidiangal.org), founded in 2001 by doctor Mario Marsiajfrom Verona, provides the funds and coordinatesthe Italian voluntary doctors who cooperate withthe 4 Ugandan doctors employed by the Ugandangovernment.” From ISF web-site.

Ceccarelli A. Information without borders. Free software for African hospitals. MJoTA 2009:3(3):74-75.

uation, and, without any doubt, a lot of things goingon find in information technology use one of theirstrongest points."Another volunteer, Alessandro Domanico, is, at thetime of writing (February 2009) in Matiri, Kenya, forthe second time. At Tharaka Hospital, Alessandrotrains personnel in using information technology. Headditionally optimizes and updates the softwareaccording to difficulties and suggestions that comeup from the close contact with users.Right now, Informatici Senza Frontiere is working onthe start-up of a multilingual assistance center for allOpen Hospital users. Additionally, Informatici SenzaFrontiere is developing Open Staff, a softwareenabling human resources management. As well asOpen Hospital, Open Staff is open-source, and ischaracterized by an extreme portability and facilityof utilization, great flexibility in using and addingapplicative components.Cooperazione Internazionale (COOPI,http://www.coopi.org) is an Italian nongovernmen-tal organization founded in 1965 for developmentprograms and emergency interventions in Africa,Latin America, Asia and the Balkans, and organizeactivities in Italy to foster knowledge exchangebetween cultures. COOPI requested software devel-opment for use in the Goz Beida refugee camp, Ciad.Our organization expects this software, once com-pleted, to have broad application.Informatici Senza Frontiere is developing a softwarecalled WALKS (Web Aided Laboratory for KnowledgeSharing) which is a multilingual web application.This means that expert information technology usershelp novice users solve information technologyproblems. This software can downloaded freely fromwww.sourceforge.net: information, uploads andcontacts with Informatici Senza Frontiere volunteers

can be found at the website, www.informaticisen-zafrontiere.org.Informatici Senza Frontiere has started a collabora-tion with organizations that develop microcreditprojects in Madagascar, and gave its contribution tothe realization of a specific software supportingreport activities.Informatici Senza Frontiere is working hard toincrease awareness that more work has to be done,and is always careful in following the challenge thatthe former Secretary General of the United Nationsgave, on the previous page, which is for the coun-tries to give the poorer countries access to informa-tion and communication.By Aldo CeccarelliChief Information Officer and Business ProcessExpert at SEDAMYL SPA, joint-venture partner ofSyral (Group Tereos, France) [email protected]


INFORMATION WITHOUT BORDERS


LINKS TO INFORMATION WITHOUTBORDERSUpdates on ISF open source software:http://www.informaticisenzafrontiere.org/blog?p=446&lang=en http://www.informaticisenzafrontiere.org/blog?p=503&lang=en

Updates on Kenya:http://www.informaticisenzafrontiere.org/blog?p=466&lang=enhttp://www.informaticisenzafrontiere.org/blog?p=435&lang=enhttp://www.informaticisenzafrontiere.org/blog?p=546&lang=en

Updates on Ugandahttp://www.informaticisenzafrontiere.org/blog?p=518&lang=enhttp://www.informaticisenzafrontiere.org/blog?p=471&lang=enhttp://www.informaticisenzafrontiere.org/blog?p=450&lang=en

Updates on Madagascar:http://www.informaticisenzafrontiere.org/blog?p=498&lang=en

Updates on Afghanistan:http://www.informaticisenzafrontiere.org/blog/?p=143&lang=en

Informatici Senza Frontiere initia-tive: Cable and hardware laid downin Uganda.

RemittancesI first heard the word “remittance” about a yearafter I started sending money to Africa by WesternUnion. I do all my banking through my online bank’sweb-site which means not only do I never write acheck (I no longer own a check book) but I alsorarely handle cash. Remittances are all about cash:when I sent my money as a loan to set up the BAVaudio and video studios in Surulere, Nigeria(Nollywood) when we were making a movie onmalaria, I had to first withdraw cash from a bankand drive to a shop which was an agent for WesternUnion (http://www.mjota.org/images/mjota5Diabetes115-6movie.pdf). I then filled in a form with therecipient’s name, city and country, my contact infor-mation, and a secret question and answer that I hadto tell the recipient when I called to tell him theremittance number and amount transmitted.These transactions occur millions of times each year,probably billions of times. And in some countries,the remittances substantially increase the wealth ofthe countries. Citizens are leaving their own coun-tries to work, and send money back home.I first heard the word “remittance” and the word“transnational” at the same time. I was part of anaudience in a Philadelphia public radio station andwas watching a video made by Alex Rivera aboutMexicans working in Massachusetts, The SixthSection, who sent enough money home to build abaseball stadium.Sending remittances is expensive. This monthMJoTA heard that sending USD1,000 to India byWestern Union (http://www.westernunion.com) costUSD15, which is 1.5%. However, sending the sameamount 100 miles across the United States costUSD80, which is 8%.The World Bank (http://www.worldbank.org) knows

6 Volume 3, Number 3 2009 Medical Journal of Therapeutics Africa

HEALTH FROM WEALTH

http://[email protected]

“This paper uses a new, 2005/06 nationally-repre-sentative household survey to analyze the impactof internal remittances (from Ghana) and interna-tional remittances (from African and other coun-tries) on poverty and inequality in Ghana. To con-trol for selection and endogeneity, it uses a 2-stage multinomial logit model with instrumentalvariables focusing on variations in migration net-works and remittances among various ethno-reli-gious groups in Ghana. The paper finds that both internal and interna-tional remittances reduce the level, depth, andseverity of poverty in Ghana. However, the size ofthe poverty reduction depends on the type ofremittances received. In general, poverty in Ghanais reduced more by international than internalremittances. For households receiving international remit-tances, the level of poverty falls by 88.1% with theinclusion of remittances; for households receivinginternal remittances, poverty falls by 69.4% withthe inclusion of remittances. The paper also finds that both types of remit-tances increase income inequality in Ghana. Forhouseholds with internal remittances, the inclu-sion of remittances causes the Gini coefficient torise by 4%, and for households with internationalremittances, the inclusion of remittances causesthe Gini to increase by 17.4%.”The Impact of Remittances on Poverty andInequality in Ghana by Richard H Adams,Jr, Alfredo Cuecuecha, John Page. TheWorld Bank Development Prospects Group,Development Economics Department &Africa Region, September 2008 PolicyReseaRch WoRking PaPeR 4732N

Manhattan, New York City.World Bank convened the African Diaspora, 2008.

Waruingi WA. Health from wealth. Remittances. MJoTA 2009:3(3):76-7.

that remittances are being sent home, and MJoTAheard from World Bank officials that they would liketo collect the money from all Africans outside Africa,and put it in a big pot, and work out more efficientways of sending money home. The most efficientway, MJoTA Publisher believes, may well be sendingmoney from the person who earns it directly to thebusiness, relative or friend who needs it. The World Bank has published a number of reportson the total amount of money that is sent home incountries in Africa. One report, on Ghana, can bedownloaded from http://www-wds.worldbank.org/external. Its abstract is reproduced on page 76.Outlook for Remittance Flows 2008-2010: Growthexpected to moderate significantly, but flows toremain resilient by Dilip Ratha, Sanket Mohapatraand Zhimei Xu was published in the 11 November2008 Migration Brief. The authors assess trends intransmitting remittances until 2008, and give a pes-simistic forecast for the next years because the glob-al financial markets collapsed. The report gives esti-mates of the total amounts of the remittances forindividual countries: during 2007, USD18billion wassent to Nigeria; and the remittances sent to Tongaand Lesotho were respectively 35% and 20% oftheir gross domestic products.Their forecast: “After several years of strong growth,remittance flows to developing countries began toslow down in the third quarter of 2008. This slow-down is expected to deepen further in 2009 inresponse to the global financial crisis, although theexact magnitude of the growth moderation (or out-right decline in some cases) is hard to predict giventhe uncertainties about global growth, commodityprices, and exchange rates. In nominal dollar terms,officially recorded remittance flows to developingcountries are estimated to reach USD283 billion in2008, up 6.7% from USD265 billion in 2007; but inreal terms, remittances are expected to fall from 2%of GDP in 2007 to 1.8 % in 2008. This decline, how-ever, is smaller than that of private or official capitalflows, implying that remittances are expected toremain resilient relative to many other categories ofresource flows to developing countries. In 2009,remittances are expected to fall by 0.9% (or at theworst case, no more than 6%). Migration flows fromdeveloping countries may slow as a result of theglobal growth slowdown, but the stock of interna-tional migrants from developing countries is unlikelyto decrease. Remittance flows from the GCC coun-tries are likely to fall more than those from the USand Europe, affecting recipient countries in theMiddle East and North Africa and South Asia.”By MJoTA Publisher, Professor WanjiruAkinyi Waruingi BSc(Hons), PhD


HEALTH FROM WEALTH


Government building in one of America’s poorestcities, Camden New Jersey. Inscribed in stone nearthe top of the building is “Knowledge is power.”

The 52nd anniversary celebrations of Ghanaianindependence at the New York City house of theGhanaian Ambassador to the United Nations, 06March 2009. Below, MJoTA Publisher, ChiefLookman Sulaimon, and the Ghanaian DeputyAmbassador.

The PanAfrican AcupunctureProject (PAAP)Our project is a training program which is distinctfrom a program that brings professional practition-ers to provide acupuncture treatments,http://www.panafricanacupuncture.org. Thus far wehave conducted trainings in Uganda and Kenya. Ourtrainees are all local healthcare providers: nurses,nurse midwives, midwives, physiotherapists, andtraditional healers, and the Trainers are volunteerlicensed acupuncturists. Training local providers bet-ter guarantees that access to acupuncture will con-tinue long after we leave. These pictures are of ourgraduating class and their patients.Acupuncture is a 3,000-year-old Asian approach totreatment. Although I do not know whether a simi-lar treatment modality developed anywhere in Africaindependently, I do know there has been a presenceof acupuncture across the African continent.However, it has been accessible only to those withmoney. In Uganda, there are a handful of acupunc-turists, but almost noone has had acupuncture. So,our project has brought access to acupuncture thathas never before existed. Most patients who aretreated have never heard of acupuncture before. Although there are practitioners of acupuncture inmany African countries, such as South Africa andKenya, as far as I know, such a program that trainsthe local providers has never before existed in thecontinent of Africa. Acupuncture is not meant to be a substitute for con-ventional biomedical treatments. The acupuncturetreatments, working synergistically with convention-al treatments, reduce the symptoms of HIV/AIDS,malaria, tuberculosis, and other common conditionsas well as the side effects associated with pharma-ceuticals. We have found, however, that the treat-ments often address symptoms that have resistedother treatments. Because of the immediate effect

of the treatments, our Trainees feel more empow-ered and more directly involved in the health of theirpatients. Often they have reported that with"tablets" they never know if their patients improveor not. They return to their homes and villagesbefore any results, if any, are ever seen. With theacupuncture, they see immediate and often dramat-ic results. On numerous occasions, I have heard thatthe patient goes home and their family is so happy,the family's happiness a measure of the success ofthe treatment. As far as I know, there has not beenany research to show that patients infected with HIVwho receive acupuncture actually live longer.However, they are able to be more productive andhave a greater quality of life. We do know thepatients do feel better and are able to return to workand to their gardens.We have worked in collaboration with an organiza-tion called THETA, whose mission is to help bridgethe gap between traditional healers and biomedicalproviders. This includes teaching UniversalPrecautions, proper record keeping, and the signsand symptoms associated with conditions that needto be referred to conventional medical providers. (Ofnote is that the World Health Organization reportsthat about 80% of Ugandans still access traditionalhealers, and this number is in line with my ownobservation.) The people at THETA have been very


HEALTHCARE IN AFRICA


Richard Mandell, Lic.Ac.New England School of AcupunctureClinical Supervisor, 1990–2007New England School of Acupuncture Student, 1987–90Brown University Master of Arts, Creative Writing, 1977–9Oberlin College Bachelor of Arts, Psychobiology, 1971–5.

Mandell R. Healthcare in Africa. The PanAfrican Acupuncture Project. MJoTA 2009:3(3):78-80.

supportive of the work we are doing. Andso we decided to train a group of tradi-tional healers. We have been soimpressed with their commitment, inter-est, and dedication, in many cases muchgreater than the biomedical Trainees. Asacupuncture really is a traditional folkmedicine, it has much in common with thetraditional healing practices of the healers.Their compassion and dedication to theirpatients is truly remarkable. So, this hasbeen a piece of what we have accom-plished that is greatly satisfying to us.Acupuncture relies on the fact that thebody knows how to heal itself. What itdoes is help when there is an imbalanceand strengthen when there is a weakness.So the immune system gets stimulated and support-ed and the body is better prepared to fight off infec-tion. In 1989, I was among a group of acupunctur-ists who created an acupuncture clinic for those whowere infected with HIV. It continues to this day andhas been highly successful. In 2001, when I startedreading for the first time stories in the Americanpress about how bad the epidemic was in Africa, Iimmediately decided that I had to go to help. Soonafter, I realized that one individual just could not doenough, even though I believe the Jewish adagethat "to save one life is to save the world." That iswhen I decided that creating a training programwould greatly increase access to a treatment modal-ity that I already knew to be highly effective. (I mustadd that all through my youth I had an interest inAfrica.)Is acupuncture more effective outside the Westernmedical systems? Yes, and no. I have not found thattraining physicians in acupuncture is useful. We didthis at our first training and quickly realized that,though interested intellectually, the physicians hadno interest, or found it impossible to integrateacupuncture into their very busy schedules.However, those health workers who report to physi-cians, such as nurses and midwives, feel empoweredby learning acupuncture and do everything possibleto integrate it into their work. From my experiencein Africa, I believe that integrating acupuncture intothe medical system will best serve the population.Because the treatments often provide immediateand dramatic effects, patients are very compliant.Thus, the acupuncture can even serve as a gatewayto other medical interventions. Although there arecertainly the same ego and control issues withphysicians that we see here in the United States,Uganda as a whole seems more open to do anythingthat will help the people. I think this was particular-ly true of Uganda's approach to addressing the




wanting to save the countryusing all means. Yes, ifmore providers knew howto use acupuncture, therewould be less suffering,better quality of life, andgreater overall productivity.Finally, the fact that wehave been very successfultraining the TraditionalHealers associated withTHETA demonstrates thateven those providers whonormally work outside theconventional medical sys-

tem can employ acupuncture to help the people.As I said, training the nurses and midwives doesgive them something that the doctors do not have.As in the United States, it is the nurses who alreadytruly provide the real care. With the addition ofacupuncture, they can even better address theneeds of their patients.By Richard Mandell Lic.Ac. Mr Mandell is a licensed acupuncturist, and Founderand Director of the PanAfrican Acupuncture Project.Contact e-mail: [email protected]. Allen Magezi is in-country Uganda Coordinator,[email protected], 256 772 470883.




Malaria: Current trends in diagno-sis and treatment.PATHOPHYSIOLOGY

Malaria is a disease caused by parasites of thePlasmodium genus and is transmitted to humans bythe female Anopheles mosquito. Plasmodium Vivax,Plasmodium Ovale and Plasmodium Malariae causea benign form of malaria while PlasmodiumFalciparum gives rise to a malignant form of malar-ia that may lead to death if left untreated.Nonspecific clinical symptoms associated with rup-ture of the erythrocytes following invasion by theparasites include chills, fever, headache and generalmalaise. In the case of Plasmodium Falciparum fur-ther complications include vascular collapse, severe

anemia, renal and respiratory failure, and cerebralmalaria presenting as seizures or confusion, pro-gressing to stupor, coma and death.(1)EPIDEMIOLOGY

Malaria continues to dominate despite rigorous com-bative measures worldwide to control the disease- an estimated 300 to 500 million humans are infect-ed resulting in more than a million deaths arereported annually to the World HealthOrganization.(2)Malaria is endemic to the tropics and subtropics, andareas of sub-Saharan Africa. In the United Statesmalaria was eradicated in the 1950s, yet 1,337humans infected, which included 8 deaths, werereported in 2002.(3) This has been mainly attributedto the importation of malaria from malaria-endemiccountries by the residents of the United States.DIAGNOSIS

Clinical diagnosis is inconclusive due to the nonspe-cific signs and symptoms of mild and severe malar-ia. Definitive diagnosis is made by microscopicexamination of both thick and thin peripheral bloodsmears identifying the presence of the parasite andthe degree of parasitemia enabling species-specifictreatment. Antigen detection using Rapid DiagnosticTests (RDTs) was approved by the United StatesFood and Drug Administration (FDA) on 13 June2007 under the stipulation that the tests be per-


CENTERS FOR DISEASE CONTROL


Mosquito net in hotel in the Rift Valley in Kenya.MJoTA Publisher was in the malaria-endemicregion 36 hours, slept under this net, and wasdiagnosed with malaria 7 days later. Note the rip inthe net. Below, Kenyatta University Director ofResearch Charity Gichuki BVM, PhD working ondocuments on a Sunday afternoon in the RiftValley, Kenya. Photos, MJoTA Publisher.

Vathada S. CDC. Malaria: Current trends in diagnosis and treatment. MJoTA 2009:3(3):81-2.

formed by hospitals and laboratories only, with fol-low-up confirmation by microscopy.(4) Serology byindirect immunofluorescence (IFA) or enzyme-linkedimmunosorbent assay (ELISA) detects previous anti-bodies and is therefore not a reliable marker fordiagnosis. Molecular diagnosis using the polymerase

chain reaction (PCR) to detect the nucleic acids ofthe parasite is most accurate but is expensive andrequires a specialized laboratory.TREATMENT

Uncomplicated malaria: Oral chloroquine is thedrug of choice for Plasmodium Malariae,Plasmodium Ovale, non chloroquine-resistantPlasmodium Vivax and uncomplicated non chloro-quine-resistant Plasmodium Falciparum.Chloroquine-resistant Plasmodium Vivax infection istreated with quinine plus doxycline or tetracycline,or mefloquine. The treatment for uncomplicatedchloroquine-resistant Plasmodium Falciparumincludes quinine plus doxycline or tetracycline, oratovaquone-proguanil, or mefloquine. Severe malaria: Intravenous artesunate for thetreatment of severe malaria in the United States hasnot been approved for marketing in by the Food andDrug Administration. It can however be used underthe provision of the Investigational New Drug appli-cation (IND) of the Centers for Disease Controlwhich went into effect on 21 June 2007 followingFDA approval. Thus it is available to patientsenrolled in FDA-approved clinical trials of theCenters for Disease Control Drug Service at theCenters for Disease Control Quarantine Stations.REFERENCES

1. CDC Malaria: Disease. At http://www.cdc.gov/malar-ia/disease.htm.2. CDC Malaria: Malaria Facts. At http://www.cdc.gov/malaria/facts.htm.3. CDC Malaria: Malaria Facts. At http://www.cdc.gov/malaria/facts.htm.4. CDC Malaria: Diagnosis. At http://www.cdc.gov/malar-ia/diagnosis_treatment/diagnosis.htm. 5. CDC. Artesunate available to treat severe malaria in US.http://www.cdc.gov/malaria/features/artesunate_now_available.htm.

By Sohini Vathada MDDr Vathada is a medical writer and medical scienceteacher in Atlanta, Georgia; [email protected].


CENTERS FOR DISEASE CONTROL


Malaria Surveillance --- United States, 2006The majority of malaria infections in the UnitedStates are in travellers from malaria-endemicareas. In the United States, infection can occurthrough exposure to infected blood products, con-genital transmission, or local mosquito-bornetransmission. Malaria surveillance is conducted toidentify episodes of local transmission and toguide prevention recommendations for travelers.Description of System: Malaria cases confirmedby blood film or polymerase chain reaction aremandated to be reported to local and state healthdepartments by healthcare providers or laboratorystaff members. Case investigations are conductedby local and state health departments, and reportsare transmitted to CDC through the NationalMalaria Surveillance System, National NotifiableDiseases Surveillance System, and direct CDC con-sultations. Data from these reporting systemswere the basis of this report.Results: CDC received 1,564 reports of malariasymptoms in humans living in the United States in2006, 6 of which were fatal. This was an increaseof 2.4% from 1,528 reports for 2005. P falci-parum, P vivax, P malariae, and P ovale wereidentified in 39.2%, 17.6%, 2.9%, and 3.0% ofcases, respectively. Ten patients (0.6%) wereinfected by 2 or more species. The infectingspecies was unreported or undetermined in36.6%. Compared with 2005, the biggest increas-es in malaria were in travelers from Asia (16.0%).Based on estimated volume of travel, the highestestimated relative rates of malaria were in travel-ers from West Africa. Of 602 United States civil-ians who acquired malaria abroad and for whomchemoprophylaxis information was known, 405(67.3%) reported that they had not followed achemoprophylactic drug regimen recommendedby CDC for the area to which they had traveled.Seventeen reports were of pregnant women, ofwhom only one reported taking chemoprophylax-is. Six deaths were reported; 5 had been infectedwith P. falciparum and one with P malariae.Edited from abstract in CDC publication, MMWR,20 June 2008, 57(SS05):24-39 by Sonja Mali,MPH, Stefanie Steele, MPH, Laurence Slutsker,MD, Paul M. Arguin, MD, Division of ParasiticDiseases National Center for Zoonotic, Vector-Borne, and Enteric Diseases. WAW

Garden inmalaria-endemicLagos,Nigeria

We clean school toilets to keepchildren in schoolSince I was very young, I recognized the importanceof education. My father was a school inspector andmy mother, a school principal. Both my parentsencouraged us 5 children to take pride and joy in oureducation, resulting in us all now being highly qual-ified professionals.I loved school so much, I used to remain there longafter the last bell had rung, and I always volun-teered to help with ground maintenance or odd jobs.This love of education has remained with me, andafter noticing more and more children off schoolgrounds during school hours, I was driven to findout why. I questioned over 100 children about theirtruancy and many replied that they were going tothe toilet, which led me to the schools to investigate.I found filthy, filthy toilets, which shocked me somuch that I have devoted my life to cleaning schooltoilets and schools in general.The Clean Shop has a mission to teach everyone,especially school children, to refuse to use dirty andunhygienic public toilets and to protest loudly andvigorously dirty public toilets.I was one of the first trained black geologists inSouth Africa and worked as chief geologist on one of

South Africa’s largest mines, with all the perks of awell paying job such as company cars and a house.I resigned from this comfortable job to follow a newpath, to clean toilets, and to give back to the edu-cation system that served me and my family so.We protest dirty toilets, we clean the toilets,and we keep the toilets clean. CLEAN TOILETS CHANGE LIVES

In effective sanitation, the process and the methodscan be as vital as the facilities themselves. Peoplemay know the location and purpose of a sanitaryfacility, but not how to use it correctly, vastly under-mining potential impact. Building pipes or construct-ing facilities without also building a system of main-tenance or education leaves you with very little. I


THE CLEAN SHOP


Changemakers.netSchools Sanitation Improvement andEnhancement Project: Enhancing the Educational,Hygienic, Health and Safety EnvironmentCountry: South AfricaOrganization: The Clean ShopField of Work - SanitationYear the initiative began: 1996Project URL: http://www.thecleanshop.co.za

Mulaudzi FT. The Clean Shop. We clean school toilets to keep children in school. MJoTA 2009:3(3):83-6.

run The Clean Shop on the principle that clean facil-ities are the most powerful form of persuasion—themore visible the change, the more convincing aremy strategies. Personally, I seek to win hearts and minds of my fel-low people through clean toilet facilities, and therest would follow. More basically, I realized our mostpowerful impact would emerge from changing theway people used toilet facilities in their daily lives,and creating a culture of personal accountability forsanitary practices.I approach the problem from the perspective of aneducator rather than a cleaning contractor. I teachthe skills to maintain facilities and use them correct-ly. I have sought to inspire a change in attitude,teaching people to refuse to use dirty toilets. In mythinking, cleaning facilities is what ensures contin-ued use—“no one wants to use a dirty toilet, no mat-ter how poor they are.”WHAT WE DO

• Develop the approaches in the use of the emerg-ing private sector in contributing to the sustainableimprovement of sanitation in the schools.• Develop and implement training and awarenessprogram for better use of sanitation facilities inschools linked to vigorous teaching of fundraisingprojects by the schools to be able to continue on

their own once The Donor and Corporate fundinghas sown the seed and stopped funding.• Stimulate the sense of ownership by the commu-nities in their schools by initiating a serious cam-paign in public participation processes.HOW WE KEEP CHILDREN IN SCHOOL

The Clean Shop cleans and maintains school toiletsby employing parents as toilet cleaners and moni-tors. The parents are properly trained, motivated,supervised and equipped to undertake the massivecleaning task. The result is that the cleaning andhygiene maintenance of school toilets becomeseffective and sustainable. Toilet paper which was notusually available, which leads to rapid blocking ofthe water borne systems when other wiping materi-als such as socks, newspapers, stones, grass, areused, is issued to each child weekly.Initially, building new toilet facilities was thought tobe a solution of getting rid of dirty toilets, but werapidly found that this was not enough as even newtoilets quickly became dirty, blocked and unusable. FUTURE PLANS

In collaboration with University of Venda, I intend tostart a parent teaching education system that willteach parents how to clean and maintain clean toi-lets in the schools based on the following plan:The Clean Shop intends to partner with theUniversity of Venda on a drive to formally educateunemployed women in the Venda region and providethem with permanent employment thereafter.Through the partnership the University of Venda willoffer a short course on the dynamics of cleaning andhygiene and will provide an accredited certificateupon completion. The Clean Shop will deploy 3 grad-uates at each of the 100 schools, thus permanentlyemploying 300 women. This approach will:• Create clean, safe and useable school toilets forpublic schools in Venda• Create school environments that are conducive toseamless teaching and learning• Empower school children with life skills on theimportance of maintaining clean toilets at home andat school• Educate, train, and employ women from under-developed areas in Venda• Facilitate skills transfer on the dynamics of sanita-tion and hygiene to women and school children• Empower disadvantaged women with skills andknowledge to actively participate.CLIENTS

Currently The Clean Shop has industrial cleaningcontracts for big clients that include:


THE CLEAN SHOP


AngloGold Ashanti Limited is the largestgold mining company in Africa. This is theirtestimonial about The Clean Shop.“We hereby confirm the following:We would like to rate their performance under thefollowing drivers:1. Safety and Health: - They apply safety stan-dards as per our requirements and theirstaff/cleaners are trained accordingly.2. Cost: - Very efficient and competitive. Alsoassist in cost saving campaigns.3. Production: - Standard of hygiene and cleanli-ness is excellent and backed by our HealthInspector’s monthly audits. Kitchens, ablutionblocks and change houses are kept spotless cleanand toilets clean all the time 24 hours a day everyday of the year.4. Technology: - The Company uses latest tech-nology available and always prepared to look atnew innovations.5. People Development: - Have a well motivatedstaff and develops own people for better positionswithin the company. Since The Clean Shop incep-tion in June 2002, the company has never experi-enced any industrial action.”

• AngloGold Ashanti Limited West Wits OperationsMine Hostels Cleaning• University of Venda Students Residences Cleaning• Harmony Gold Mines Toilets and Change HousesCleaning• National Union of Mineworkers (NUM) Officescountry wide cleaning• Royal Bafokeng Nation 10 Schools Cleaning inRusternburg• President Supermarket in Fochville cleaning• Once off Deep Cleaning project for varies compa-nies like factories and petrol stations.Two partnerships go back to June 1996: AnglogoldAshanti Limited and Harmony Gold Mines. All part-nerships were created by our marketing strategy ofhighlighting to our clients that we have a value solu-tion to their sanitation needs and negotiating work-ing for them. Since 1996 we have never been dis-missed from a contract due to non performance, thesingle termination resulted from a business closing.OUR IMPACT

Our impact can be summarized by the way teachersand educators in the schools we work with havestarted using the same toilets as the school kids, asthey now appreciate that a clean toilet is for every-body, not only for teachers.BARRIERS WE FACE

The main barriers we face in creating an environ-ment which could speed up our achievement of ourimpact is that the Government is failing to realizethat the following problems have been positivelyidentified in our schools and many parts of world:• There is serious lack of sanitation infrastructure inall if not most of our schools• This situation negatively impacts on learning capa-bilities of scholars when they have to leave school tofind a toilet in the bush or in the neighborhood• There is poor health and mental development ofpupils, especially now with the outbreak of choleraand many other diseases• Social and cultural issues are that school pupils arenot supposed to clean their schools’ toilets, thusthere is a need for private sector involvement• As the problem of sanitation in the schools is notbeing addressed, more and more black children arehating and abandoning schooling, contributing neg-atively to the economic development of the region.WE CARE ABOUT SAFETY

Other measures of the impact of our innovationrevolve around the safety issues of using industrialcleaning chemicals and equipment. This can be rein-

forced by the following statements.Safety is a constraint. Any new initiatives must besafe even when replacing practice that is even lesssafe such as filthy and unsightly ablution blocks. Theargument of the lesser of the two evils cannot beapplied to hazards associated with sanitation anduse of cleaning chemicals.The whole solution is dependent on the success ofhygiene education and environmental awarenesssince no cleaning system can survive the constantabuse of toilets. Hygiene education is dependent ona working cleaning system, since pupils are unlikelyto be responsive to hygiene, health and safety mes-sages if the school toilets are filthy.SOUTH AFRICAN GOVERNMENT POLICY

There is no government policy intervention in SouthAfrica. We keep on talking to the stakeholders inGovernment, but we are sure that sooner or laterthey will start hearing us, as did our current clientslike the University of Venda, AngloGold Ashanti lim-ited, Harmony Gold Mines, Royal Bafokeng Nationand their King, National Union of Mineworkers andPresident Supermarket in Fochville. These organiza-tion made it their internal policy that clean hygienictoilets and living areas are always clean as they pro-vide them with happier and healthier employees.BENEFICIARIES OF OUR WORK

Our beneficiaries are all the school children inschools we work with in South Africa and fortunatestudents at the University of Venda, as well as theadults who are working on Gold Mines and in allbuilding facilities we maintain clean in the country.Also important beneficiaries are all the people andparents we who work with us who are permanentemployees of The Clean Shop and their families. Notforgetting all the owners of buildings we renderservices in as they know for sure that their employ-ees and themselves are guaranteed clean officesand toilets all the time they are away from home andthey are at their workplaces. FINANCING FOR THE CLEAN SHOP

Our initiative is self financed. Although our opera-tions are completely directed to solving social prob-lems like lack of proper and adequate sanitationfacilities, for the sake of sustainability and growth,we work for profit. Unlike most non-governmentalagencies in the world, we never pursue fundingorganization for project funds. We just carry on withmarketing our services to organizations and compa-nies that appreciate clean and safe environment forall the people that use their facilities like sports sta-diums, mine hostels, where public toilets are indemand to be kept clean all the time of the day.Therefore we charge a fee for our services and we


THE CLEAN SHOP


do not work for charity and we do not utilize volun-teer workforce, as we believe that everybody whohas worked must be paid a fair salary.It is worth saying it here that we will never turndown a funding offer from any source. CURRENT SOURCES AND STREAMS OF REVENUE

Our current annual budget is USD2,203,539 Ourannual budget for 2006 and 2005 was USD937,846.Our current sources of income are from the cleaningcontracts we have with the following clients:• AngloGold Ashanti Limited West Wits OperationsMine Hostels Cleaning• University of Venda Students Residences Cleaning • Harmony Gold Mines Toilets and Change HousesCleaning• National Union of Mineworkers (NUM) Officescountry wide cleaning• Royal Bafokeng Nation 10 Schools Cleaning inRusternburg • President Supermarket in Fochville cleaning • Once off Deep Cleaning project for varies compa-nies like factories and petrol stations.WHY THE CLEAN SHOP STAYS IN BUSINESS

The potential demand for our innovation is huge.Everybody, everywhere in the world, people go tothe toilet more than once a day. Of all the people ofthe world and below heavens, nobody would like touse a dirty toilet. It is not high rocket science thatwe all love to use a clean toilet irrespective of oursocial standing, whether we are female or male,African, European, Asian, which religion we have,our sexual orientation, whether we are able or dis-abled, tall or short: we are all human and we allneed the dignity of a clean toilet.FINANCIAL SUSTAINABILITY

The main barriers to financial sustainability arecaused by organizations who solely rely on grantsand handouts for their survival. The Governments ofthe world and funding organizations should also notonly rely on non-governmental organizations to per-form critical duties to uplift communities from pover-ty and despair, and only be willing to assist the non-governmental organizations.Ashoka Social Entrepreneurs like me and my com-pany The Clean Shop should also be assisted withfunds as we are also contributing tremendously touplifting our people through employment opportuni-ties and clean safe toilet facilities. By Fhauwni Trevor MulaudziMr Mulaudzi is the founder and owner of The CleanShop, www.thecleanshop.co.za, motto “Agents of

change in Southern Africa”. Contact by e-mail:[email protected], and by telephone, 27-82-325-1051 or 27-82-973-1082.


THE CLEAN SHOP


From the Publisher of Medical Journal ofTherapeutics AfricaMr Mulaudzi and 2 other Ashoka Fellows fromAfrica visited the United States in February, and Iwas privileged to meet them at the AshokaFoundation Headquarters in Virginia, towards theend of the Metro Orange line. The previous time I was in Washington was to cel-ebrate the inauguration of President Obama onthe streets (15th and Pennsylvania Avenue), in aKenyan Embassy Party (Thomas Circle) and at aKenyan Inauguration Ball (Silver Spring), soAfrican successes and achievements were verymuch on my mind.The 3 Ashoka fellows I met are all involved in san-itation: architect Mr David Kuria builds toilets inKenya’s Kibera, arguably the biggest slum inAfrica, engineer Dr Joseph Adelegan recycleswaste from slaughter houses in Ibadan, Nigeria. The biggest shock was listening to Mr Mulaudzi.He is a big cheerful, happy, passionate man wholoves everyone and everything, and especially hiswife of 30 years whom he met at the University ofWittwatersrand when she studied medicine and hegeology. He talked about her love and support andbrilliance several times during our interview. And he loves, loves children, and the knowledgethat he is keeping children in school by cleaningtoilets. Of course, what he is doing is restoringdignity, telling children they are worthy of humandignity and that education is worthy of them. He happily showed me pictures of really disgust-ing toilets, I could almost smell them, but I keptlooking. After a few minutes he looked at me andsaid he was amazed I was carefully studyingeverything, most people turn away. I had not real-ized that turning away was an option; because hedid not turn away and MJoTA exists to bear wit-ness to visionaries whose vision is to help themost helpless in a most unphotogenic way. MJoTA applauds the Ashoka Foundation for spon-soring Mr Mulaudzi and applauds the Mulaudzifamily for choosing a filthy job so that children canhave brighter futures.

03 FEBRUARY 2009Tough times everywhere. We are hearing fromLagos that the amount of money sent back from rel-atives and friends outside Nigeria (the World Bankdefines this as "remittances from the Diaspora") hasdropped sharply. However, the number of naira thata dollar will buy has increased from about 117(when I was in Lagos in April) to over 160. So anydollar sent buys more than it did. Or would if infla-tion was not taking a large bite.I am also hearing that the laws have been changedin Nigeria for importing cars. I have friends whoseliving comes from going to car auctions and sendingcars on ships to Lagos. No cars are manufactured inNigeria, which is the world's leading exporter of lightcrude oil. Every car is imported. Nigerian law nowprohibits import of any car manufactured more than8 years ago. So going to the auction and buying aserviceable car for USD200 to 300 and sending it toNigeria does not work anymore. Especially whenincome is sharply down in Nigeria. The collapse ofthe financial institutions in the United States hasseverely affected business all throughout Africa.Most striking for me is the loss of jobs in the phar-maceutical industry. On a MJoTA road-trip to NorthJersey yesterday, I went with 4 brilliant, well-groomed, highly educated professionals (all beauti-ful ladies over 40) to a job fair (together, our quali-fications are enough to run a small hospital, or asmall pharmaceutical company). What struck us wasthe age and bearing of the job fair attendees: most-ly 40s and 50s, mostly management. Lack of avail-able money has shut down clinical trials, researchand development, made companies focus on stayingalive now rather than their future. Certainly drugs,devices and biologics are being tested by clinicaltrial, but fewer. MJoTA strongly believes in the

future: we are watching and listening and prayingthat the clever financial people will figure what to doso the pharmaceutical industry looks far, far aheadagain.Meanwhile, MJoTA is gearing up to start publishing2009, volume 3 number 2 on 15 February. And get-ting ready to start celebrating Black History Monthlectures on Thursday. Do join us.


DAILY UPDATES


Waruingi WW. Daily Updates. February. MJoTA 2009:3(3):87-94.

Job fair in the Northern winter, Philadelphia 2008.

Professor Ekundayo (Deputy Provost, Ambrose AlliUniv), Pastor Edoro and recording engineer in BAVaudio and video studios in Surulere, Nigeria.

08 FEBRUARY 2009I have been busy sorting out articles forthe February issue of Medical Journal ofTherapeutics Africa, hosting medicalwriter Elana Stolpner MD who has beenvisiting from Ohio, going with her to a jobfair and to visit clinical trial professionalsand prospective employers, and cleaningmy house. I like order, and I like clean,but when I am focused on editing andlaying out, bombs could fall and holescould be punched in my walls and I donot notice.And bombs have been falling, and I havebeen slow to realize. My youngest son is20, a keen athlete, 6'4" tall, 195lb, runsevery day, lifts weights, does not drinkalcohol, take any drugs, nor animal or animal prod-uct. Completely vegan, no animal has had anythingto do with anything he eats. I had not noticed thathe stopped taking multi-vitamins, and that his dietwas soy milk, oatmeal, Chinese vegetables, rice andpizza. He collapsed today after Quaker religiousservices, fainted dead away and awoke with abnor-mal heart rhythm and clammy hands.We have a sign in our Quaker Meeting, that "it takesa Meeting to raise a child." By the time I stoppedfocusing on MJoTA enough to turn on my phone, the2 Quaker men who have taken on the role of fatherto Al and his sister had taken him to the emergencyroom, and all sorts of tests were in progress. Al'sgodfather is the father of my 2 older sons, he is alsoa physician on staff at the hospital. He came to seehim, looked at his eyes (he is an ophthalmologist),talked to the Emergency Room doctor, and agreedwith me in the knowledge that Al's brain and heartlooked normal: Al has a nutritional deficiency.Al's father called from Germany, our daughter textedhim from the hospital, he is ready to hop on a planeto see his only son; Al's eldest brother traveled fromNew York City. We are a family, and this is how wecome together when one of us needs help. Everyonepitching in financially, emotionally.So the way ahead: I bought huge bottles of vita-mins, Al is writing a food diary, and I will work withMJoTA Business Administrator Deidre Adore (whoalso is a nutritionist with 20 years experience) andwe will figure out what he needs. Nothing will evermake Al eat dairy or eggs or meat or fish. So wework with what he can eat.Being nutritionally deficient in a situation of plenty isAmerican. Being nutrionally deficient because food islacking is also becoming American. I have startedreading stories about food lines and food stampsand hunger. These stories are likely to increase as

the tsunami that resulted from houses being boughtby people with no money and by houses being worthless than the mortgages.


DAILY UPDATES


Upper, restaurant in Pennsylvania; middle,University of Pennsylvania Clinical Trials Co-ordi-nator Lisa Desiderio; lower, forest near MJoTAheadquarters.

09 FEBRUARY 2009The continent where 2 of my 3 brothers live, wheremy parents died, where I was educated from ele-mentary school through PhD, the continent ofAustralia is on fire. All weekend the news has beenof the state of Victoria burning and humans perish-ing (over 170) because they did not have enoughtime to get out of the way. I also hear that 37 firesare raging across my home state of New SouthWales (which is immediately to the north of Victoria,immediately to the south of Queensland).A decade ago I wrote a novel, publication of whichmy career as a medical writer interrupted, calledWhen Fire Jumps. I have seen fire jump over awooden shed and burn down a substantial 2-storybrick building. I have been surrounded 360 degreesby fires that were a mile or more away, and then thewind changed and the danger vanished as quickly asit came.Every year Australia burns. We never had bushesand trees near our house near the University of NewSouth Wales because of that: planting close to ahouse is to tempt the fire.A century ago a young girl wrote a poem of longingfor Australia when she was far away. We weretaught her poem in school, and now I remember,she speaks for me:"I love a sunburnt country, A land of sweepingplains, Of ragged mountain ranges, Of droughts andflooding rains. I love her far horizons, I love herjewel-sea, Her beauty and her terror - The widebrown land for me!" Dorothea Mackellar 1885-1967.10 FEBRUARY 2009I read a post on LinkedIn about the need for manu-facturers in Africa to learn about how to sell theirproducts in the United States.Medical Journal of Therapeutics Africa published anessay in which the author made the case that unlessmanufacturers know how to market their productsto supermarkets, and learn how to buy shelf space,they will not be able to penetrate the American mar-

kets (access this article from http://www.mjota.org/images/mjota_issue7LeadershipMach.pdf.)I am interested in hearing from manufacturers whowant to export. I know clothes manufacturers exportfrom Africa to the United States, and certainly tea,cocoa, coffee is exported (but I would not call thosemanufactured products). I really don't know whatelse is being made, and I would like to know.When I go to Nigeria, I stay in the house of a man-ufacturer: she has 2 factories making plastic bagsand they certainly don't make enough to export.Nigerian food heavily depends on tomatoes, andfrom what I was told, all canned tomatoes areimported from other countries.Drugs are certainly not exported from West Africa,or from East Africa. Wish they were, but the manu-facturing capacity is just not there. We published anarticle on pharmaceutical manufacturing in MedicalJournal of Therapeutics Africa, which was writtenafter attending the Corporate Council on AfricaHealth Forum in November in DC. We are talkingabout the pharmaceutical industry and initiatives tonurture its development in Africa in our Black HistoryMonth webinars.


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Lagos, Nigeria, manufacturing plastic bags, above.Left, billboard in Lagos. Below, wrecked car thatwas repaired to look new in Lagos.

19 FEBRUARY 2009Today I arose at 4:30am to drive to Washington toGeorgetown University to listen to a lecture andpanel discussion on HIV/AIDS and philanthropy.They were all there! The Gates Foundation, PEPFARare the big names. I heard for the first time thatPEPFAR is planning to train 140,000 health workersto combat HIV/AIDS. I want to know more. We willtalk about the panel tonight in the Black HistoryMonth webinar, and about HIV/AIDS in general.When I worked as a full-time paid medical writer, Ispent over a year working entirely on HIV/AIDSprojects, all over the United States, and was sent toGreece and Spain.

20 FEBRUARY 2009I realized this morning that I have not taken a dayoff since I nearly froze to death at PresidentObama's inauguration, but then neither hasPresident Obama, so why should I. However, thePresident has a whole country on call for him, andMJoTA has a group of trusty volunteer editors andstaff.In the interests of MJoTA really being a force fortransformation, and the continuing problems we arehaving with GoToMeeting, I have decided the fol-lowing.We invite anyone interested to be the guest speak-er at our informational meetingsWe have 3 themes for the Thursday meetings:i how diseases are handled across Africaii development of a microcosm pharmaceuticalindustry in a country in Africaiii encourage the development of an all-Africa regu-latory authority for pharmaceuticals, devices, biolog-ics and vaccines.


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14 FEBRUARY 2009Happy Valentine's Day! MJoTA loves you, becauseyou are reading MJoTA. MJoTA loves you becauseyou care about health in Africa. Caring abouthumans you will never meet, and the only reasonyou care is because they are human: this is thesupreme act of love and on this day MJoTA cele-brates you and sends you love and blessings.I never really was much for falling in love with men,more like loving a man on a parallel track, and I loveyou still. I love my children most (because mothersare their greatest advocate), and my coworkers andrelatives. My cat, whose birthday is today: this is notso much love as coexisting in an armed truce. Thenature of love is permanent, someone I love, I loveforever. That is the way love works for me, I forgiveeverything and believe to my DNA in redemption. IfI love you, nothing you can do can make me stoploving you.My preferred style is to fall in love with a country, oreven a continent. I fell in love with Australia when Iwas about to leave it; I fell in love with Americawhen I came here, I fell in love with Germany whenI spent a sabbatical there in 1986, and with Nigeriawhen I was warmly welcomed into the Nigeriancommunity in Philadelphia, Baltimore and the sub-urbs of Washington.I say without reservation that I love the continent ofAfrica. I love the countries of Africa, the peoples ofAfrica. I may be the only European who showed upat a wildlife park in Kenya and decided against goingin because the benefit to me was not worth the costof the ticket (I should pay to see cats!). But I didtake plenty of pictures of Americans swarmng in tolook at the lions. And school children from Kenya.God bless them all, I love them too.

I remember the time and the date and where I waswhen I started loving the 53 countries of Africa. Iwas in London, walking through Westminstertowards the bridge crossing the Thames to theFlorence Nightingale museum in St Thomas'Hospital. May 5, 2005. 11am. I had just walked pastthe statue of Nelson standing on a high pedestal,and the statue of Florence Nightingale. Walking paststatues strewn with red poppies to remember theend of World War II, 60 years previously. I sudden-ly became aware that the tall buildings ofWestminster were built on the blood of Africa, and Iknew that every breath, every penny from then onwould be expended in redemption for the sins of myancestors.My Valentine's Day wish for you is to love what youlove. Pick them up when they fall. Help them how-ever you can. Be creative in letting them know thatyou are there for them, guiding them if you are theirelder. Forgive them what they have done in the past,and do everything you can to make sure the evilthey have done is not visited on anyone else.Because that is an act of love for all humanity.


DAILY UPDATES


Left, Publisher at wedding in Lagos;above, deaf girls in school in Lagos;below, Patience Dodgson with friend.

21 FEBRUARY 2009Yesterday I stayed in Washington overnight,because Neema Mgana invited me to come to theheadquarters of the Ashoka Foundation to interview3 scientists from Africa whose passion for scienceand humanity have intersected into viable projectsthat are improving the lives of many in their owncountries.I rode on the metro all the way through Washingtonacross the river to Virginia. And met 3 gentlemenwho work has transformed the lives of many aroundthem. I did not hear that any of them came up withtheir ideas at a large, expensive conference inFlorida, or anywhere, or a United Nations missionreception in the Helmsley Hotel to talk about pover-ty in Africa. What I did hear was 3 hard-working pro-fessionals kept their ears to the ground, saw a needthat was obvious to everyone except those who goto large conferences and receptions, and figured outways of addressing the need.Trevor (with red hat) kept seeing children walkinghome when they should have been in school, andthe answer to his question "why are you not inschool?" was "because we need to go home to usethe toilet," transformed his life, that of his wife (amedical doctor, they met as university students inSouth Africa) and thousands of children. Quite sim-ply, what Trevor does is clean toilets. (The CleanShop. We clean school toilets to keep children inschool. FT Mulaudzi. Med J of Therapeutics Africa2009:3(3):83-6; accessed at http://www.mjota.org/images/mjota2009vol3no3pp83-7thecleanshop.pdf)David Kuria is an architect (with blue hat) who builttoilets and implemented a system for their main-tainence in the Kibera slums. I took his picture, buthis National Geographic took my interview time. Hisprofile from the Ashoka Foundation: “David success-fully constructed and manages hygienic public sani-tation facilities in Kenyan slums and other informal

settlements. He engages urban communities in thedesign and construction of his IKO toilet. David hasmade sanitation facilities a profitable venture for theurban poor as well as the business community bycollecting dues and providing innovative financingschemes in collaboration with local and internation-al financial institutions and funding partners.”I interviewed Dr Joseph Adelegan (in gray jacket),and will feature him in a future issue of MJoTA. Fromhis profile on the Ashoka Foundation website: “DrJoseph Adelegan has brought technological innova-tion to conventional anaerobic biodigesters. Hedesigned a reactor dubbed Cows to Kilowatts thattreats slaughterhouse waste in an effort to abatewater pollution and mitigate greenhouse gas emis-sion. He engages local communities in the imple-mentation of his project which produces biogasusable as domestic cooking gas to create a com-mercially sustainable solution to a persistent envi-ronmental problem.”


DAILY UPDATES


25 FEBRUARY 2009Today the British newspaper announced the death ofa child who suffered from birth from cerebral palsyand epilepsy, with picture of him with his father kiss-ing him. He was 6, and he was the son of the BritishLeader of the Opposition. The Prime Minister isknown to have lost an newborn daughter, and havea small son with cystic fibrosis, which is likely toshorten his son's life.Children die of disease and injuries to the brain inrich countries. What is unlikely in a poor country isthat the sons of either men would survive beyondinfancy because they both need expensive constantmedical and nursing attention. And anything couldkill them: certainly malaria would do it.The Prime Minister stated it best "The loss of a childis something a parent should never have to bear."World Malaria Day 25 April. We need to lessen theburden of malaria. Children are dying.27 FEBRUARY 2009The last week in February is always nuts, the monthsometimes has an extra day in it, and when it does,the whole world stops to play games together in thesummer, and the games are called the OlympicGames because the Greek gods hang out on MountOlympus. Not this year. No extra day, no OlympicGames. February ends firmly at midnight tomorrownight. The Greek gods do not like this abrupt end,and so they sow discord, fear, and lack of trust in theminds of mortals.MJoTA has been in chaos because 1) we are completing vol 3, no 2, 2) individual members continue to be harassed byowners of a web-site who are trying to shut usdown and want USD1million (or is it USD1billion?)3) we have all been sick a little bit (me) or a lot(others)4) I have been finalizing materials and schedulesfor 3 classes of medical writing webinars that starton Monday5) I am getting some of our people ready to writea clinical document for a wonderful company, 6) the Ivorian delegation came to Philadelphia.Let's get this out in the open. Cote D'Ivoire is cool.Cote D'Ivoire sits next to Ghana in West Africa, isglobally the greatest producer of cocoa, has a pop-ulation size the same as my lovely Australia, and theIvorian flag has the same colors as the country ofmy mother, Ireland. Philadelphia, by which I meanthe great and greatly loved Stanley Straughter (graysuit, top picture; black suit, red tie, front, squattingin bottom picture), put together a 3-day programwhich started and ended by good wishes inPhiladelphia City Hall.

After the business forumon Wednesday, I met ChiefLookman Sulaimon (darkblue suit, middle picture),who is trained in graphicart, journalism and busi-ness. He publishes NY Echo, a free print and onlinenewspaper, http://www.nyecho.com. The Chief, andhe is a real Chief in Nigeria (Borokinni of Ojora-Lagos), is preparing to expand his African communi-ties newspaper to Philadelphia, [email protected].


DAILY UPDATES


Volume 3, Number 3 2009 Medical Journal of Therapeutics Africa

DAILY UPDATES


During the Thursday visit to West Philadelphia to theEnterprise Institute (in the building where AmericanBandstand was produced), I met Dr Eric Edi (bottompicture, previous page, translating into French thewords of Carol Brooks; left, second from right; bot-tom left, second from left) who is Chairman of theIvorian Diaspora group, and is in the running to berecognized as the pre-eminent African scholar andteacher of history of Africans in and out of Africa.After the official farewell in the Philadelphia caucusroom, Dr Edi organized a dinner in a house-restau-rant in West Philadelphia, filled with gentle French-speaking Ivorians who live around Philadelphia orwere visiting from Cote D'Ivoire. We ate rice andpepper fish. Wonderful. More and more I wonderhow I survived a childhood in England, Ireland, NewZealand and Australia eating boiled carrots, boiledcabbage, boiled meat. Often all boiled together.MJoTA is an occasional visitor to the Cote D'IvoireEmbassy (below, Christophe Kouakou, Deputy Chiefof Mission) in Washington DC. It is on MasschusettsAvenue, the walk from Dupont Circle and the Centerfor Global Development passes the bronze statue ofGhandi that I frequently photograph, and theEmbassy of another small country that defines EastAfrican cool: Kenya. MJoTA was there first in June,and again in August for the celebration of theIvorian independence from France.MJoTA has come to the conclusion that independ-ence from any oppression is a good thing, and that

kicking outoppressors inthe NorthernH e m i s p h e r esummer is areally good idea,b e c a u s eEmbassy inde-pendence par-ties are wonder-ful outdoorswith flowersblooming in thelong August

summer evening ofWashington. However, MJoTAenjoyed the respite from thecold winter that was the KenyanUnited Nations mission party inDecember. MJoTA hopes forblessings on the Cote D'Ivoire,and wishes the 17-member del-egation safe journeys.By Wanjiru Akinyi WaruingiBSc(Hons), PhD

Recombinant human antithrombin PRESS RELEASE FROM THEMANUFACTURER (EDITED)Framingham, MA, andDeerfield, IL, 06 Feb, 2009 –GTC Biotherapeutics andOvation Pharmaceuticals, Inc.announced today that the U.S.Food and Drug Administration(FDA) approved ATryn®(Antithrombin [Recombinant])for the prevention of peri-operative and peri-partumthromboembolic events in hereditary antithrombindeficient patients. It is not indicated for treatment ofthromboembolic events in hereditary antithrombindeficient patients. Recombinant human antithrombin is the first evertransgenically produced therapeutic protein and thefirst recombinant antithrombin approved in theUnited States. With its approval, the FDA’s Center forVeterinary Medicine also approved GTC’s NewAnimal Drug Application, the first of its kind to reg-ulate genetically engineered animals. This is nowrequired for a recombinant technology used todevelop transgenic animals, such as the goats thatproduce recombinant antithrombin. GTC has grant-ed Ovation the right to market recombinant humanantithrombin in the United States and pursue furtherclinical development.(1) The companies expect it tobe available in the second quarter of 2009.Humans with hereditary antithrombin deficiency areat increased risk for venous thromboembolic events,including pulmonary embolism and deep vein throm-bosis, which can be life-threatening, particularly inhigh risk situations.(2) Antithrombin is a naturalanticoagulant with a role in controlling the formationof blood clots.(2) Purified recombinant antithrombinhas the same amino acid sequence as antithrombinderived from human plasma.(3)This drug was developed to provide a safe and con-sistent supply of recombinant antithrombin.(3)Its safety and efficacy was established in clinical

studies conducted in hereditary antithrombin defi-cient patients with a history of thromboembolicevents in the United States, Europe and Canada.During these studies, prevented the formation ofclinically overt thromboembolic events.


BIOLOGICS


PRESCRIBING INFORMATION (PI)FOR ANTITHROMBIN III“THROMBATE III is prepared from pooled units ofhuman plasma from normal donors....”CLINICAL PHARMACOLOGYAntithrombin III (AT-III), an alpha2-glycoproteinof molecular weight 58,000, is normally present inhuman plasma at a concentration of approximate-ly 12.5 mg/dL2,3 and is the major plasma inhibitorof thrombin.”FOR RECOMBINANT ANTITHROMBIN“...a recombinant antithrombin indicated for theprevention of peri-operative and peri-partumthromboembolic events in hereditary antithrombindeficient patients. It is not indicated for treatmentof thromboembolic events in hereditary antithrom-bin deficient patients.Antithrombin (recombinant)... is a recombinanthuman antithrombin. It is a 432-amino acid glyco-protein..molecular weight approximately 57,215.”

Goats in Nigeria.Photos, Jessie Edoro.

MJoTA Editors. Biologics. Recombinant human antithrombin. MJoTA 2009:3(3):95-6.

COMPARABILITY OF RHAT AND HPATSTRUCTURE-Same primary and secondary structure-Some glycosylation differenceFUNCTION-Increased heparin binding of rhAT-Same inhibitory activity for thrombin & Factor Xa From FDA Advisory Board Meeting on 09 Jan2009, http://www.fda.gov

The prevalence of hereditary antithrombin deficien-cy in the general population is approximately 1 in2,000 to 1 in 5,000.(4,5) Half these patients mayexperience a thrombosis before 25, and, up to 85%may suffer a thromboembolic event by 50.(6,7)This is the first time recombinant antithrombin hasbeen approved anywhere, and the first antithrombinproduct that has been approved through the cen-tralized procedure in the European Union.(8) It isnow also the first recombinant antithrombin productapproved by the FDA.The serious adverse reaction reported in clinicalstudies is hemorrhage (intra-abdominal, hemarthro-sis and post procedural). The most common adverseevents reported in clinical trials at a frequency of >5% are hemorrhage and infusion site reaction.The process for producing recombinant humanantithrombin involves scientists inserting DNA forthe human antithrombin protein into a single-celledgoat embryo. This embryo is implanted into a surro-gate doe. The resulting transgenic offspring are ableto produce high levels of antithrombin in their milk.This protein is collected and purified from the milk,which is administered intravenously to patients.REFERENCES

1.GTC Biotherapeutics, GTC Biotherapeutics and OvationsPharmaceuticals close agreement to market and developATryn® in the United States2.The National Alliance for Thrombosis and

Thrombophilia. Antithrombin Deficiency: An In-DepthGuide for Patients and Health Care Providers. 20063.ATIII.com – A Resource for Information on HereditaryAntithrombin Deficiency (HD)4.Maclean PS, Tait RC. Hereditary and acquired antithrom-bin deficiency: epidemiology, pathogenesis and treatmentoptions. Drugs. 2007;67(10):1429-40. Review5.Patnaik MM, Moll S. Inherited antithrombin deficiency: areview. Haemophilia. 2008 Nov;14(6):1229-396.Lane DA, Mannucci PM, Bauer KA, Bertina RM, BochkovNP, Boulyjenkov V, Chandy M, Dahlbäck B, Ginter EK,Miletich JP, Rosendaal FR, Seligsohn U. Inherited throm-bophilia: Part 1. Thromb Haemost. 1996 Nov;76(5):651-62. Review. 7.Anderson FA Jr, Spencer FA. Risk factors for venousthromboembolism. Circulation. 2003 Jun 17;107(23 Suppl1):I9-16. Review8.GTC Biotherapeutics, European Commission approvesATrynEdited by MJoTA Editors


BIOLOGICS


CLINICAL TRIALS LISTED IN CLINCIALTRI-ALS.GOV ON PATIENTS WITH HEREDITARYANTITHROMBIN DEFICIENCY

1. RECOMBINANT HUMAN ANTITHROMBIN(RHAT) IN PATIENTS WITH HEREDITARYANTITHROMBIN DEFICIENCY UNDERGOINGSURGERY OR DELIVERY. A Multicenter,Multinational Study to Assess the Safety andEfficacy of Antithrombin Alfa in HereditaryAntithrombin (AT) Deficient Patients in High-RiskSituations for Thrombosis. Completed. Phase IIIclinical trial.2. STUDY TO ASSESS RECOMBINANT HUMANANTITHROMBIN IN PATIENTS WITHHEREDITARY ANTITHROMBIN DEFICIENCYUNDERGOING SURGERY OR DELIVERY. AMulticenter, Multinational Study to Assess theIncidence of Deep Vein Thrombosis (DVT)Following Prophylactic Intravenous Administrationof Recombinant Human Antithrombin (rh AT) toHereditary AT Deficient Patients in High-RiskSituations. Phase III clinical trial.

EDITED ABSTRACTDickneite G. Biopharm Drug Dispos. 2008Sep;29(6):356-65. A comparison of the pharma-cokinetics of antithrombin derived from humanplasma and from transgenic goats and the pre-vention of sepsis in an animal model. DeptPharmacology and Toxicology, CSL Behring GmbH,Marburg, Germany.Antithrombin (AT) is the principal inhibitor ofthrombin and other serine proteases of the coag-ulation cascade. AT has previously been preparedfrom human plasma (hpAT), and a transgenic vari-ant from goat milk (tgAT) is now available.Two open-label, parallel pharmacokinetic studiesin rats (n=18) and rabbits (n=18) compared plas-ma concentrations of hpAT and tgAT followingintravenous administration; the efficacy of the 2preparations in prolonging survival from bacteri-al-induced sepsis was compared in 2 open-label,randomised, placebo-controlled studies in rats(n=266). Maximum plasma concentrations wereapproximately dose-proportional and were similarfor both hpAT and tgAT. The elimination of tgATwas faster than hpAT, and the t(1/2) of hpAT waslonger than that of tgAT in both rats (0.85-1.92 hversus 0.17-0.73 h) and rabbits (19-38 h versus1.5-2.2 h). Correspondingly, tgAT showed a lowerarea under the curve, mean residence time, phar-macokinetic response to dosing and a higherclearance rate. In a meta-analysis of the efficacystudies, the overall hazard ratio for death was1.36 (tgAT:hpAT; p=0.06; 95% CI 0.99-1.86).HpAT and tgAT have differing pharmacokineticproperties in pre-clinical studies.

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