Animal facilities

Warning: There are a few somewhat graphic/disturbing images toward the end of this post.

Another area of interest in Djibouti is related to vector-borne and zoonotic disease (pathogens carried by insects and animals). Each year, over three million animals are transported from Ethiopia, Somalia and Sudan, through Djibouti, to the Arabian peninsula and Gulf states, so there's huge potential for an outbreak of an emerging disease or the spread of an endemic disease. To develop a surveillance system for these types of diseases, I first met yesterday afternoon with a representative from the Ministry of Agriculture. With his support, today, I am trying to visit three main animal facilities in the country - the animal quarantine facility, the national slaughterhouse - to determine if any would be suitable for disease surveillance and/or research.

This morning, I started the day with a trip to the animal quarantine facility which receives all animals for quarantine as they arrive in Djibouti. I was given a full tour of the facilities and learned about the systems by which animals are received and shipped. Unfortunately, I didn't get many pictures inside the facilities (it's owned by a private Saudi Arabian company and the owner who was showing me around didn't seem very pleased when I asked if I could take pictures) but I took a few pictures of the camels just outside the gate.

Camels waiting to enter the quarantine

Camels being herded into the quarantine - each one is inspected and vaccinated as it enters

After gathering all the information I needed at the quarantine facility, I headed to the slaughterhouse. In Djibouti, animals are slaughtered over night to avoid the heat of the day and so that the meat is available in the market first thing in the morning, so by the time I arrived, no animals were being killed, but I still had a full tour of the facility. First I walked through the holding areas where animals are kept before slaughter.
From here, the animals are brought inside to the slaughtering areas.
The carcasses are then loaded onto trucks to be transported to the markets for sale.
Their hides are treated with salt and laid outside to dry in the sun before being sold in bulk to leather producers.
I spent a lot of time at the quarantine and slaughterhouse facilities, so I wasn't able to visit the livestock farm near town, but I felt like I had seen enough. By the end of my time in the slaughterhouse, I was pretty much ready to move on and hop on a plane out of Djibouti.

Housecall

I've had a cough for about two weeks now, and earlier this week, it was actually so bad that I lost my voice for two full days. My voice has only just begun to return and I'm still coughing a lot, so I sound like a mess (even though I feel just fine). My contact in the Ministry of Health (who, as a sidenote, may become the president of Djibouti within the next few years) noticed this tonight while we were meeting around 8:30 p.m. in the lobby of my hotel (his schedule is always packed so usually the only time I can get a couple hours of his time is pretty late). He interrupted our meeting to say he would be back in half an hour - he was worried about my cough and was going home to get his stethoscope and prescription pad. I tried to explain that I was fine, but he was insistent, so I figured it couldn't hurt to get a physician's advice and finally agreed. Half an hour later, he returned to the hotel and after a quick check-up, wrote me a prescription. Before I could begin to wonder how I would ever get the prescription filled, he had sent his driver to the pharmacy and told me the driver would deliver the prescription within an hour. I was all set!

Centre Paul Faure

Tuberculosis (TB) is a huge issue in Djibouti, so my first stop was Centre Paul Faure (CPF), the national reference center for tuberculosis. CPF sees about 9,000 patients per year for diagnosis of TB and many more for follow-up and treatment. The patients are of all ages and come not only from Djibouti but also from neighboring countries such as Ethiopia and Somalia, where diagnostics and treatment are unavailable.
Even though Djibouti is estimated to have the highest prevalence of TB in the world, the laboratory capacity for diagnosis is very limited. Diagnosis is based primarily on smear microscopy, which only detects about half of all positive cases tested, and there is no testing for drug susceptibility that could identify drug resistant strains of TB and allow patients who have resistant strains to have appropriate clinical follow-up.

One of my biggest projects in Djibouti, then, is to improve laboratory capacity for TB diagnosis at CPF. We're going to introduce a new TB diagnostic called MODS (microscopic-observed drug-susceptibility assay) for the diagnosis of all new suspect cases of TB at CPF. The test provides more accurate results (it detects 97% of all positive cases tested!) and also allows drug sensitivity testing for first line TB drugs. Plus the results are available much more rapidly than traditional cultures (most of the time within 5-7 days) and each test costs less than $3.

MODS is a really promising new technology for TB diagnosis, especially in countries like Djibouti. The only issue right now is that we have to turn the following spaces into biosafety level 2 laboratories before we can implement the test. It's going to be a challenge but hopefully we'll be able to do it!

Back in Djibouti

I’m back in Djibouti for trip number three. It’s a quick one this time, planned at the last minute and just three days long, but hopefully it will be productive. The majority of the protocols and projects that I’m managing are in Djibouti so even though I’m only here for a short period of time, I have a lot to do. Over the next couple days I’ll be holding meetings, conducting assessments, visiting sites, making new contacts and following up on previous meetings for a number of projects including:

• Surveillance for vector-borne and zoonotic diseases in human, animal and insect populations at the local slaughterhouse and in the animal transport section of the port,
• Management of HIV-positive patients with suspected drug resistance to antiretroviral treatment,
• Study of drug resistant gonorrhea in patients seeking treatment for sexually transmitted infections at the national reference center,
• Study of sexually transmitted infections and HIV genotyping and drug resistance in commercial sex workers,
• Capacity building for diagnosis and surveillance of multi-drug resistant tuberculosis (MDRTB) at the national tuberculosis reference center,
• Construction of a central public health laboratory to serve as a reference laboratory and surveillance center, and
• Hiring of a local person to assist with the coordination of these and other activities.

There’s a lot to be done and I know that only gives a vague overview of what it all entails, but I’ll try to write more and post some pictures after each meeting.

Port of Djibouti

Today was meant to be filled with scheduled meetings - with the Secretary General of the Ministry of Health, the director of the country's only medical school, the director of the government's Center for Research and Development (CERD) and the director of the U.S. Agency for International Development (USAID). At the end of the day, though, one more meeting was added to our schedule as a surprise - a meeting with the Harbour Master and head of security at the Port of Djibouti.

As I already hinted earlier when discussing why I'm working in Djibouti, the Port of Djibouti is at the crossroads of one of the most important shipping routes in the world.
The reason for the meeting with the directors of the port, though, was not directly related to transportation or shipping, but rather, more appropriately, to health, specifically the health of port employees and the animals that are shipped through the port. Over two million animals are transported through the port each year, coming from Ethiopia, Somalia and Sudan and going to Yemen and Saudi Arabia. The directors of the port expressed concern that these animals may carry diseases, to which port employees are then exposed, either by direct contact with the animals or by airborne transmission from the animal pens to nearby offices. They requested our help in developing a surveillance system to monitor these animals for vector-borne and zoonotic diseases. Although we couldn't make any promises up front, I think I may have the perfect project in mind to meet their needs. I'll discuss more later!(Random note: Photography is normally prohibited in the port, but since we were guests of the Harbour Master and the head of security, we were allowed to snap a few shots!)

National HIV/AIDS Program

My main purpose on this trip to Djibouti is to spend a few days working with the country's National HIV/AIDS Program, trying to improve their surveillance system, develop their capacity for testing patients for sexually transmitted infections (STIs), plan a system for monitoring drug resistance in patients on anti-retrovirals (ARVs) and build epidemiologic capacity among program staff. It's been a lot of work to try to accomplish in just a few days, but I've enjoyed it significantly. The staff of the National HIV/AIDS Program in Djibouti is great. The director of the program is a quiet Djiboutian man; the deputy director is a kind-hearted Congolese man (from Congo-Brassaville, not the Democratic Republic of Congo); the technical advisor is a bright Burundian woman; and the head of surveillance is an energetic Djiboutian woman. It's obvious that each has a true passion for and interest in the work they are doing, so it was a pleasure to work with each of them. I just wish I had more time so that I could do more!

Sunsets in Djibouti

The sunsets in Djibouti are absolutely beautiful - every single night. We've started making a point of being back at the hotel by sunset so we can watch the sun sink over the sea and the hills in the west.

Jamal and I

Medical diplomacy

Our work in Djibouti (and many of the other countries where NAMRU-3 works) is essentially "medical diplomacy," a term which was once described in the Boston Globe by Tommy Thompson as follows

"...If we have any hope of spreading democracy and ending tyranny in every corner of the globe, it is vital that we use all of the weapons of freedom at our disposal. That includes our most effective arsenal against terrorists and the forces of oppression: education, compassion, and medicine.

That is the principle at the heart of what I call ''medical diplomacy" - the winning of hearts and minds of people in the Middle East, Asia, Africa, and elsewhere by exporting medical care, expertise, and personnel to help those who need it most.

Medical diplomacy must be made a significantly larger part of our foreign and defense policy, as we clean up from costly and deadly wars in Afghanistan and Iraq. America has the best chance to win the war on terror and defeat the terrorists by enhancing our medical and humanitarian assistance to vulnerable countries. By delivering hope we will deliver freedom."

Why Djibouti?

I'm sure one of the first questions you're asking yourself when you read that I've been spending a lot of time in Djibouti is "Why Djibouti?" Ok, the first question you ask might not actually be that one; it's more likely that "Why Djibouti?" is your second question. Your first one is probably "Where is Djibouti?" So here's a map:
Now that the first question is answered, let's move on to the second one - "Why Djibouti?"

I'll give the U.S. government perspective first (since I am an employee of the U.S. Navy). If you take another glance at the map above, you'll see that Djibouti is situated at the opening of the Red Sea. Although it's not shown on the map, at the other end of the Red Sea is the Suez Canal, connecting the Red Sea to the Mediterranean Sea, and thus connecting Europe and Asia by a sea route that doesn't require traveling all the way around Africa. Djibouti is one of two countries in the physical position to control the entrance to the Red Sea, so it's in the interested of U.S. government to ensure that Djibouti is stable so that trade and transportation between Europe and Asia is not interrupted.

Now I'll give the humanitarian perspective. Although the GDP of Djibouti is quite high, the distribution of wealth within the country is severely skewed. Unemployment averages around 45% but is as high as 60% for disadvantaged groups. Literacy is only 57% and the gender gap in literacy is significant - 73% of men are literate while only 45% of women. Life expectancy is 49%. The infant mortality ratio of 114 infant deaths per 1,000 live births is one of the highest in the Middle East or sub-Saharan Africa. Maternal mortality is also high at 740 maternal deaths per 1,000 live births. The leading causes of death are diarrhea and respiratory illness. Malnutrition is widespread and significant - 26% of children are chronically malnourished; 13% suffer from acute malnutrition. More than 40% of households do not have access to sewage and sanitation services. Djibouti has the highest prevalence of tuberculosis in the world and, although HIV prevalence is not disturbingly high, Djibouti has numerous characteristics of a country at high risk for the spread of HIV. Amidst all of this, there are only two hospitals in the country, neither of which has the capacity for laboratory diagnosis of the specific etiologies of the leading causes of death in the country.

Combine the government perspective and the humanitarian perspective, and you'll have a better understanding why I'm working in Djibouti: (1) because the U.S. government is willing to invest a significant amount of money to ensure that Djibouti stays stable, and (2) because the people of Djibouti need assistance.

Kempinski Hotel

The hotel where we stay in Djibouti is one of my favorites. I feel a little spoiled every time we go because the hotel is beautiful, right on the shore of the Red Sea, with a pool overlooking the sea and a small beach, and the most comfortable beds I think I've ever slept in. It's a real treat to stay there.

Arriving at the gate of the hotel (with all our trunks and boxes!)

View of the hotel from the beach

Room at the Kempinski