Maverick Citizen

FAILING HEALTH SYSTEMS OP-ED

Poverty trap: 70 million in Africa infected with viral hepatitis with number growing rapidly

Poverty trap: 70 million in Africa infected with viral hepatitis with number growing rapidly
70 million people in Africa are infected with viral hepatitis with figures rapidly rising. (Illustration: iStock)

Last week two important new declarations were launched in Cape Town at the World Congress of the International Hepato-Pancreato-Biliary Association and the African Viral Hepatitis Convention. 

The Declarations aim to draw attention and hopefully action to another global health emergency, viral hepatitis, and one of the fatal liver diseases it causes: Hepatocellular Carcinoma. The Deputy Director General of the Department of Health, Dr Anban Pillay, who was at the global conference, publicly signed one of the declarations.

The million-life question is whether any action will follow.

In the encyclopedia of viruses that pose a threat to human health, viral hepatitis — a family of viruses (including hepatitis A, B, and C) that attack the liver — is well known. They have been around for decades. Their epidemiology, who is most at risk of being infected, and pathology, how it affects our health, is also well understood.

That does not mean that hepatitis is not a threat.

In fact, the opposite. According to a report released by the World Health Organisation (WHO) earlier this year, “the disease is now the second leading infectious cause of death globally — with 1.3 million deaths per year, the same as tuberculosis, a top infectious killer”.

This is now twice the number of people who die every year as a result of the human immunodeficiency virus (HIV).

Most of these deaths, nearly 300,000, take place in Africa. And the tragedy is that they should all be preventable.

hepatitis

(Graphic: Slide from presentation by Prof Wendy Spearman, Division of Haematology, UCT)

For over 40 years there has been a vaccination for hepatitis B (HBV), which should be administered at birth. Hepatitis C (HCV), if diagnosed early enough, can be treated and cured with a short course of therapy taken for 8-12 weeks.

Read more in Daily Maverick: Breakthrough cures for hepatitis C slowly becoming more widely available in South Africa

With these medical interventions in their armoury, the WHO passed a resolution in 2016 committing governments to the elimination of hepatitis by 2030. This makes it all the more concerning that there is evidence that the epidemic is now growing exponentially in some parts of the world.

In addition, it’s a particularly cruel disease.

Most hepatitis B infections either take place at birth, because of vertical transmission from mother to child (a mode of transmission that was once common with HIV), or in Africa, invariably horizontally between children before the age of five. However, because there is almost no antenatal screening in Africa, the vast majority of women are unaware of their hepatitis-positive status.

hepatitis C

Egyptian doctors making a test during an unprecedented campaign to test 50 million people to detect and treat hepatitis C patients in a bid to eliminate the disease, Cairo, Egypt. 11 November 2018. (Photo: Reuters/Mohamed Abd El Ghany)

Infants born HBV+ live unknowingly with the virus, until in their twenties and thirties they develop liver cancer (HCC) and are diagnosed and typically survive for less than a few weeks or months.

By contrast, the median survival for patients diagnosed with hepatocellular carcinoma (HCC) is more than 60 months in Taiwan, 60 months in Japan and 24, 31 and 33 months in Europe, South Korea and North America respectively.

In Africa, young people with HBV are literally cut down in the prime of life.

A disease of inequality and inaction

Leaders of governments around the world are currently debating the text of a proposed Pandemic Treaty. There is also much talk of universal health coverage, one of the Sustainable Development Goals. If governments need a rationale for either they need not look further than the health system’s failure to prevent and treat hepatitis.

Hepatitis is an example of what happens when health systems fail in the basics and when there is an unequal prioritisation of disease control depending on whose lives matter.

Read more in Daily Maverick: Viral hepatitis does not wait for the effective implementation of policy

The African Viral Hepatitis Convention Declaration of Cape Town pointed to the following stark facts:

  • 63% of the global burden of hepatitis now occurs in Africa.
  • This year, 771,000 new HBV and 172,000 new HCV infections will occur in Africa
  • In Africa, only 18% of babies received a hepatitis B birth dose vaccination.
  • Less than 1% of patients in sub-Saharan Africa are undergoing curative treatment, compared to up to 55% in high-income countries.
hepatitis

(Graphic: Slide from presentation by Prof Wendy Spearman, Division of Haematology, UCT)

Acknowledgement: Slide from presentation by Prof Wendy Spearman, Division of Hepatology, UCT

Today, HBV and HCV look very much like HIV did in its early days: it is surrounded by stigma and denial. Because hepatitis C is associated with injection drug use and homelessness, it affects people that most governments already criminalise or overlook.

For these reasons, at the conference, scientists, clinicians and civil society organisations were united in their desire to see a new activism around viral Hepatitis.

The role of the Treatment Action Campaign (TAC) in revolutionising the response to HIV/Aids was frequently cited. As a result of activism deaths due to Aids have dropped by nearly 70%, and HIV is managed in even the poorest of countries.

The Declaration complained that “Our leaders lack the political will [and] have failed us by not demonstrating that they truly care!”

It demanded “The immediate:

  • “prioritisation of national elimination plans (National Strategic plans) — vaccinate — prevent — screen — treat;
  • “allocation of the needed resources and domestic funding; and
  • “political will and commitment to institute policy and remove discrimination.”

Where there’s political will there’s a way 

South Africa is not exempt from facing a growing hepatitis epidemic. There is no routine surveillance for HBV or HBC. But prevalence studies amongst at-risk groups have shown a high prevalence of both viruses. And with the explosion of injection drug use around drug combinations including heroin, nyaope and wonga, there is evidence that numbers are growing fast.

Dr Anban Pillay

Dr Anban Pillay. (Photo by Gallo Images / Financial Mail / Russell Roberts)

Dr Anban Pillay, Deputy Director-General in the Department of Health, admitted that while “South Africa does have a Hepatitis Action Plan … it’s lying on the shelves”. He’s right. The plan was developed in 2017 and its architects argued that, if it had been implemented in its first five years, “13,000 HBV-related and 7,000 HCV-related deaths” could have been prevented.

The authors of an academic article about an investment case for the plan went on to argue that: “If scale-up continues beyond 2021 in line with WHO goals, more than 670,000 new infections, 200,000 HBV-related deaths, and 30,000 HCV-related deaths could be averted.”

Instead, it would appear that we did nothing.

On a panel with activists (including myself), Pillay told the closing session of the African Convention that “if we can deal with the viral transmission competency we can reduce the disease burden significantly”. He said there was a need “to add HBV to the existing vaccination programme and to train more nurses”.

Finally, Pillay offered to hold a meeting with experts and activists to consider areas for intervention and to put the HAP back on track. DM

Mark Heywood is a social justice activist and former Editor of Maverick Citizen, a section of Daily Maverick. He is the former Executive Director of SECTION27, a current board member of the Treatment Action Campaign and has been a human rights activist most of his life. He also worked for Change Starts Now for a period.

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