Senate Hearing Committee on Unsafe Health Care and the HIV/AIDS epidemic in Africa
Oral Testimony of
Dr. John Kiwanuka Ssemakula (MD, MPH) Washington DC, USA, 31st July 2003

Senators, thank you for affording me the honor and privilege to address this Senate Hearing Committee on the very important subject of "Safe Health Care in Africa". My name is John Kiwanuka Ssemakula a Ugandan Doctor currently working as a Public Health Consultant with the Africa-America Institute. I trained as a Doctor at Ibadan University, Nigeria, and Makerere University, Uganda. I also run a website called Medilinks which publishes health related information for Africa including that of HIV/AIDS.

I have had a professional and personal relationship with HIV/AIDS throughout my tertiary education, both in medical school, and then my on-the-ground experiences as a young physician first undertaking a medical internship, and as a medical officer in the early 1990's, during the peak period of the HIV/AIDS crisis in Uganda.

My interest in HIV/AIDS is not just professional, it is also on an intensely personal level. I have lost several cousins, who were like brothers and sisters to me over the years. One was a doctor, another was an engineer doing a Masters, others were in university. I have also lost aunts and uncles who left behind orphaned children that we have helped educate and bring up over the last 15 years.

I have been following the issue of unsafe healthcare and its role in the spread of HIV/AIDS in Africa, for a year, from the time researcher David Gisselquist sent me a draft of his ground-breaking paper almost a year ago and the controversy that ensued when it was published in the International Journal of STDS & AIDS.

As far as I was concerned people who were discussing the issue in terms of controversy were missing the point completely, for there was no controversy. It was not about the percent of HIV/AIDS that was transmitted via the unsafe use of needles, be it 2.5%, 10% or even 40%. It was simply about safe health care, the first and most basic thing a health worker should provide. I have since learnt that relatively cheap technologies such as auto-disable syringes made by BD or Star or even retractable syringes that could help deal with the problem already exist.

I've just come back from Uganda where I've been talking to people about the issue of unsafe health and the possibility of getting AIDS through needles…. None of the people I talked to saw any controversy. No one jumped to the conclusion that providing safe health care would lead to more unsafe sex. People had equal concerns about safe health care and safe sex, saying we need both.

While in Uganda I also attended the Uganda Bishops Council, where they were taking landmark decisions on Adolescent Youth Sexual and Reproductive Health. They were very excited to hear that I could be testifying before the Senate. All agreed that the issue of re-use of needles was very important. "We are sending you as our emissary to USA and we are trusting you to tell the Senators about us. Tell the Senators, we are also working very hard. We appreciate any and all help you can give us in our fight against HIV/AIDS"

I also visited Health centres in Uganda, first in Rakai district where AIDS was first seen in Uganda and then in Luwero district. Sister Namperwa of Kakuto Health Centre in Rakai District said to me, " If you have these auto-disable syringes and you can bring them to Uganda it will be good. It will help Doctors at those clinics further up country, they are just stuck, and are worn out delaing with AIDS everyday. This is a problem they have no means to deal with!"

While at Luwero Health Centre I asked Sister Margaret Serunjoji, the In-Charge of the Maternity wing if there was a problem with the re-use of needles. She said in immunization there was no problem, except when they were running low on supplies. But she said they had nothing similar for curative services. When I told her about the existence of auto-disable syringes and the moves to make them available in Africa, she became excited.

Sr. Serunjoji said "This is just what we need. Even though we do not re-use needles here because the supply is generally good, sometimes we run out. When that happens patients are forced to buy syringes. But the problem is even at 300 shs (15 cents) it is still too expensive for most villagers. So when a patient comes with their own syringe they will tell the doctor to give them their needle so they can go back and boil it and re-use it. They do not want to buy a syringe every time because it cost too much. "

I remarked "Isn't it particularly dangerous especially with the danger of HIV/AIDS in Uganda, isn't there the possibility of it being spread this way?"

Dr. Ssekabira replied, "This is a very real problem. It is even more urgent if one realizes that when the patient buys a needle sometimes they share one needle among their family, using it over and over again or may even share with their neighbours. Auto-disable syringes that were cheap enough and supplied in enough quantities would prevent this. This is not just an issue of health, but also of poverty."

All the doctors and nurses I met in the past few weeks were concerned about HIV transmission in health care settings. Because health care workers today are still living many of the same experiences that I lived through as a practicing doctor in Uganda.

As a medical student and a Junior House Officer in Mulago hospital in Kampala in the late 80's and 90's I witnessed the re-use of needles constantly. Sometimes the needles were so blunt they would actually cause trauma to the patient and blood would flow. Many colleagues recall similar stories.

So concerned were we as junior Doctors doing most of the work and in the frontline, we went on a work to rule demanding equipment such as disposable needles and gloves that would allow us to do our jobs in a safe environment, both for the protection of ourselves and our patients. I remember one time a colleague and I decided to do an informal survey of the rate of HIV on our patients. We were shocked to discover that up to 50% of our patients were HIV+ve.

While at Mulago working in the Paediatrics Department, I and colleague Dr Madewo noticed, we were seeing children presenting as HIV+ve when the mother was not. Some of the children were quite old. We thought perhaps they were being infected through immunisations or somehow by either injections or unsafe blood. Unfortunately for various reasons we were unable to investigate further. I believe this was a missed opportunity to investigate the possibility of HIV being spread in a medical setting.

There is no denying that unsafe sex is probably the major route for transmission of AIDS, but other routes such as re-use of needles and other unsafe healthcare practices are just as significant. The message of safe sex and behavioural changes to safeguard people is of paramount importance this is something the individual has control over. But they have no control over what happens in a hospital or a clinic, in this they put their trust in me the doctor, nurse of clinical officer to provide the safest possible healthcare.

Knowing this and the dangers of AIDS and other blood born diseases, should we not then be striving to achieve the safest healthcare? I say it again, how in all honesty can I stand in front of the people in rural health clinics, in villages to address them on practicing safe sex, when I know that I am not providing the highest standard of health possible. How can one in all sincerity argue against making the safest healthcare equipment available?

It is not a case of choice between safe sex or safe health care, it is quite simply that people who have been and continue to be on the frontline of the fight against HIV/AIDS, who despite battling huge difficulties and odds have succeeded in doing tremendous work, simply asking for tools that will help in the fight. It is about the fight for the future and in this there is no controversy, whatever help can be given should be provided. Can anyone in all honesty give a reason why such help or assistance should not be rendered? If so let them come to these health clinics, look these health workers in the eye and say so.

Posted August 8, 2003