Plane crash

On this date, at almost this very hour, fourteen years ago, a plane carrying Rwandan President Juvenal Habyarimana and Burundian president Cyprien Ntaryamira was on its way back to Kigali from a regional summit of heads of state in Tanzania. As the plane approached the Kigali airport and prepared to land, it was attacked by two missiles, exploded into flames and crashed into the garden of the presdential palace. Both presidents on board were killed.

Within hours, an interim government led by Hutu extremists took power and the events that would come to be known as the Rwandan genocide began. Over the next hundred days, between 500,000 and 1,000,000 Rwandans were killed. Philip Gourevitch, author of We Wish to Inform You That Tomorrow We Will Be Killed with Our Families, reports, "The dead of Rwanda accumulated at nearly three times the rate of Jewish dead during the Holocaust. It was the most efficient mass killing since the bombings of Hiroshima and Nagasaki."

The most efficient mass killing since the bombings of Hiroshima and Nagasaki.

Think about that. Only the atomic bombs used in World War II were able to kill more efficiently than the machetes and clubs wielded by common men in Rwanda in 1994.

You know you're a Southerner...

...when you haven't had water in your house consistently for over three weeks, so now that there's no water, there's absolutely no telling how long it will be before there is water; the only water you have left doesn't even fill a small pitcher, a five liter bucket and a large pot; that little bit of water has to suffice for drinking, toilet flushing, tooth brushing, bathing, dish washing and everything else; and you STILL make a pot of sweet tea at the end of the night. (It's a pot of sweet tea because I only have one pitcher and it's currently holding some of the little water that I have left.)

"You can take a girl out of the honky tonk, but you can't take the honky tonk out of a girl." (Sweet Home Alabama)

Garden growth

I'm thrilled to report that this week I had my first spinach salad (I'd actually forgotten what spinach tastes like and how good is) and I pulled three radishes as well. The garden is absolutely thriving. More radishes are almost ready to pull; the carrots are growing well; the squash and zucchini are going nuts; and the spinach and cabbage are continuing to grow. I'm so excited! Even my tomatoes, which I planted much later than everything else, have begun to sprout out of the ground. (They're the two rows of tiny green leaves in the picture.)

Mud

I spent the afternoon today working in my yard - pulling weeds, picking ripe vegetables from the garden, planting new sunflower seeds, moving never-ending piles of rocks and bricks. By the end of the day, I wasn't just dirty and sweaty; I was covered in rich, thick, dark African mud. I don't know what it is, but there's something about this mud that's different from any other mud I've walked through elsewhere in the world. It really takes hold of you. It clings to shoes, clothes, hands, legs, arms and anything else it can. And it refuses to let go. Whenever I come in from the garden, I have to scrub as hard as I can to clean my arms and legs, and, even then, after I've turned my loofah and the water draining from the shower brown, my skin is still stained with a reddish-brown tint. It's not until a couple days later that I ever notice it's completely gone.

WHO AFRO: Failing the Region

WHO's 60th anniversary celebrations have left Africa in the cold. Across the continent countries face high mortality rates and deep misery, and the regional office of the UN's specialised health organisation—WHO AFRO—has done too little to help. Clare Kapp reports from Cape Town.

The residents of the Barcelona slum in Cape Town, South Africa, are in no mood for a party. In the wind-lashed, sun-blasted shanty town, which turns to a flooded quagmire in the rain, the inhabitants are prone to diarrhoea and disease from sharing four taps and a handful of broken, padlocked toilets between 20 000 people. Many go hungry and many have HIV/AIDS.

After taking office last year, WHO Director-General Margaret Chan declared that Africa would be her top priority. “Today, the overwhelming burden of disease is borne by the African people. We must not allow Africa to become the continent left behind by development…I have identified the health of two populations as indicators of our overall performance: the people of Africa and women.” So far, the response of WHO's regional office for Africa, or AFRO, to the health challenges across the continent has been underwhelming.

In South Africa, maternal and child mortality rates are higher now in the country than in 1990, before the end of apartheid. A report, Every Death Counts, co-authored by the Medical Research Council of South Africa says that the country is only one of 12 countries—all blighted by war or HIV/AIDS crises—to have had such a phenomenon. Brazil, Mexico, and Egypt, which had similar incomes and mortality rates to South Africa in 1990, have halved the mortality of children under 5 years since 1990. If this is the fate of the continent's richest country, small wonder that most sub-Saharan African countries are likely to miss the health-related Millennium Development Goals (MDGs).

A WHO report to its Executive Board in January reported major progress towards achieving a two-thirds reduction in mortality rate of children under 5 years by 2015 in all regions except sub-Saharan Africa, where only four countries are on track to achieve the target. The mortality rate for children under 5 years in sub-Saharan Africa, which accounts for around half of the annual 9·7 million deaths worldwide, is about 160 per 1000 live births compared with 83 in south Asia, 29 in east Asia, and 27 in Latin America. It is the same bleak story on maternal mortality, where rates in sub-Saharan Africa are 920 per 100 000 live births—well over 100 times higher than in developed countries.

Progress has been made on the MDG to combat HIV/AIDS, malaria, and other diseases. Even so only about a quarter of the adults and 15% of the children who need antiretrovirals receive them, and the 1·7 million new HIV infections in Africa point to an urgent need to rethink prevention programmes. The spread of multi-drug resistant and extensively drug resistant tuberculosis has exacerbated the dual HIV-tuberculosis epidemic.

36 of the 46 countries grouped in WHO's Africa region are classed as being “in crisis” on human resources for health. Luis Sambo, the regional director for Africa, has urged governments to create the fiscal space to spend 15% of their national budget on health—only four did so in 2004 while ten more spent 10%. But some countries do not even have a functional health system, such as the Democratic Republic of the Congo and Sambo's native Angola, which is flush with oil revenues but has not yet rebuilt its infrastructure after its long civil war.

WHO has allocated US$1·2 billion or 28% of its global budget in the 2008/9 biennium to Africa, dwarfing spending on other regions. Nearly 2000 staff members work in the region. And, still, Africa is widely regarded as the weakest link in WHO's global chain.

One of AFRO's most practical problems is its location in Brazzaville, Congo. Civil war forced it to leave the country in 1997 but it has now moved its central operations back there, despite lack of accommodation for staff, frequent power cuts, poor phone lines, and other infrastructure problems—the road between the city centre and WHO's offices is so bad that a 20 min journey takes about an hour. “Dysfunctional” and “impossible to communicate with”, were typical comments health professionals made about AFRO during the research for this article. It took 4 weeks of repeated e-mails from The Lancet to elicit a response from the organisation, which said that Sambo has pushed through a series of reforms and restructuring to address weaknesses since he took over in February, 2005.

AFRO said Sambo has hired extra staff to fill vacancies in the budget and finance unit and ordered the training of 70 administrative officers at country level to give them more financial and procurement skills following damning reports by WHO's internal and external auditors about lack of financial controls and potential for abuse both at AFRO headquarters and individual country operations in Senegal and Liberia, to name but two. Already, the improvements have been striking and were acknowledged by WHO's Executive Board in January, according to Paul Lusamba, AFRO's director of programme management. Since 2006, more than 1200 posts have been established to give staff fixed-term contracts of at least a year instead of uncertain and demoralising short-term arrangements. Many of the new posts are connected to immunisation and the drive to eradicate polio “With competent and dedicated staff you can see the results”, Lusamba told The Lancet.

AFRO has 500 staff in Brazzaville but is increasingly shifting personnel into three newly created intracountry offices, which provide technical and health-systems support in southeastern, central, and western Africa, and reinforcing the country offices. These are often seen as an extension of the national health ministry, with mixed results. Countries such as Rwanda and Ethiopia have made impressive health gains thanks to targeted national policies bolstered by WHO's technical advice, whilst AIDS-ravaged Lesotho and Swaziland have been nudged into ambitious prevention and treatment campaigns. But quite often the direction seems to come from Geneva rather than Brazzaville. And observers say that in some cases, WHO would do better to break free of its cosy relationship with governments and speak out.

Stephen Lewis, former UNAIDS envoy to Africa, says he was infuriated at WHO's silence in the face of the South African health ministry's obstruction to the roll out of antiretrovirals and the provision of drugs to prevent mother-to-child transmission (PMTCT). “The South African government's delinquency has resulted in the deaths of tens of thousands if not hundreds of thousands of people and WHO never says a word. If they don't say it at the upper level then they should say it at the regional level”, he told The Lancet.

Lewis says WHO's 3 by 5 drive—which aimed to get 3 million people with HIV/AIDS in developing countries onto antiretrovirals by 2005—provided unstoppable impetus to scaling up AIDS treatment in Africa, even though it failed to reach its target. Initiatives such as the Global Fund to fight AIDS, Tuberculosis and Malaria, the Bill & Melinda Gates Foundation, the Clinton Foundation, and the US President's Emergency Plan For AIDS Relief have dramatically swollen financial resources available for health. But much of the funding is going to treatment and PMTCT at the expense of prevention and palliative care, and there is too little contribution to the human-resource infrastructure, says David Sanders, Director of the School of Public Health at South Africa's University of the Western Cape.

It also raises the question of sustainability because government health spending in countries such as Uganda is minuscule compared with the scale of funding from global health partnerships. “There is some concern that they are distorting the health system whilst also boosting resources”, Sanders says.

It is on the immunisation front that WHO and its numerous partners have achieved the most impressive results in Africa. Measles deaths in Africa fell a spectacular 91% between 2000 and 2006, 3 years ahead of the 2009 target, thanks to the combined efforts of the Measles Initiative. Between 2001 and 2006 immunisation coverage with DPT3 (three doses of vaccine against diphtheria, pertussis, and tetanus) in Africa rose from 55% to 82%, according to Sambo.

King Holmes, the William H. Foege Chair of the Department of Global Health at the University of Washington, says WHO has had a tremendous effect in boosting vaccine coverage and combating specific diseases such as leprosy, guinea worm, and onchocerciasis. He says that far from being sidelined by the multitude of global-health partnerships and foundations, WHO is a vital part of them. “The foundations need WHO to help them focus interventions, and WHO needs the foundations for the resources and leadership role”, he says.