Over the past year in response to the Mekelle University Multidisciplinary Research team publications on neural tube defects in Tigray we have been interacting with the Ministry of Health, Maternal and Child, and the Ethiopian Public Health Institute. Two months ago Dr. Afework Mulugeta and myself as well as invited international experts gave a scientific advisory of this problem to the EPHI.
Yesterday a brief was given by the EPHI which was mostly based upon our research and recommendation as well as their review of available evidence.
Officially now the Ethiopian government recognizes “that there is an alarmingly high rate of neural tube defects and folate acid deficiency in Ethiopia”. The following recommendations were made to the higher ministry officials for approval
1. Periconceptional oral folate supplementation for all women of reproductive age as an immediate solution. Low cost imported folic acid is available for the public to purchase.
2. Making the first visit for pregnancy earlier instead of the current 16 weeks
3. Promoting the consumption of folic-rich foods.
4.Implementing mandatory wheat-flour food fortification.
5.Considering salt fortification with folic acid after doing a pilot study in Tigray
6.Establishing a surveillance system for NTDs throughout Ethiopia
7. Awareness creation for all recommended interventions strategies for the prevention of NTDs
Further studies will be done on community basis and on salt
Monitoring of food fortification measures to evaluate effectiveness
The head injury problem especially that due to interpersonal violence in Tigray is a growing and significant problem which requires a public health approach.
Research published by Fasika et al showed that 24.8% of head injury admissions came from interpersonal violence from 2011 to 2014 which was before neurosurgery was permanently established at Ayder Comprehensive Specialized Hospital. Currently we are seeing about 10 patients a day and operating on 2 to 3 every day. Most of the surgeries we do are for depressed fractures caused by stone injury received in interpersonal violence. The age range of these injuries ranges from preschool to the eighth decade of life. We know there is a cultural proclivity to this type of injury but it is not well studied.
The hospital burden of head injury includes about 19% of adult ICU admissions and bedspace and 25% of pediatric ICU admissions and bed space. Our average daily census on the adult ward is 5 for head injury and on the pediatric ward also 5. The length of stay can vary from 24 hours to months with most of the surgical patients requiring a least a 5 days stay in the hospital.This burden acts to limit the care those suffering from other maladies can receive.
At the current time there is no public health or government plan to try to prevent these injuries.The World Health Organization has created a Violence Prevention Alliance which sees interpersonal violence as requiring a public health approach.
This public health approach to violence prevention seeks to improve the health and safety of all individuals by addressing underlying risk factors that increase the likelihood that an individual will become a victim or a perpetrator of violence.
The approach consists of four steps:
1 To define the problem through the systematic collection of information about the magnitude, scope, characteristics and consequences of violence.
2 To establish why violence occurs using research to determine the causes and correlates of violence, the factors that increase or decrease the risk for violence, and the factors that could be modified through interventions.
3 To find out what works to prevent violence by designing, implementing and evaluating interventions.
4 To implement effective and promising interventions in a wide range of settings. The effects of these interventions on risk factors and the target outcome should be monitored, and their impact and cost-effectiveness should be evaluated.
By definition, public health aims to provide the maximum benefit for the largest number of people. Programs for the primary prevention of violence based on the public health approach are designed to expose a broad segment of a population to prevention measures and to reduce and prevent violence at a population-level.
I propose that Mekelle University put together a multidisciplinary team consisting of not only physicians but also social scientists, public health professionals, police and prosecutors ( this was previously discussed with the head of the Tigray police who was interested), and government stakeholders. This type of investigation and policy development is exactly the type of activity which the University with all its resources and knowledge base should be tackling.
Recent research we have done at Mekelle University soon to be published has confirmed that there is a high rate of neural tube defects affecting the brain and spinal cord in Tigray. Experience suggests this is also the case in other parts of Ethiopia as well. At least 131 out of every 10,000 births is affected with some areas having almost twice that number. Defects result in death at birth for about 77% of the pregnancies affected, usually with anencephaly, while the 23% born alive usually have severe paralysis of the lower extremities and often need a operations to close the open spine, closure of myelomeningocoel, and to control pressure in the brain, ventricular peritoneal shunt, for lumbar and thoracic myelomeningocoel associated with an Arnold Chiari II malformation causing hydrocephalus. Lesser numbers of encephalocoel often requiring closure were encountered as well.
The most likely significant cause is lack of diversity in the diet and especially failing to consume foods with the vitamin folic acid. This is usually found in green and leafy vegetables as well as fresh fruits. Cooking foods such as chick peas which may contain folic acid will destroy much of it.
Around the world these birth defects have been reduced about 75% by encouraging women to plan their pregnancy and take 4 milligrams of folic acid daily starting before conception. We are working with our research group at Mekelle University to help the Tigray Regional Health Bureau and the Ethiopian Ministry of Health come up with programs to reduce these defects but this will take time.
In the meantime we encourage all women in Ethiopia to plan their pregnancy, starting folic acid supplementation before they conceive, and practice dietary diversity. They should try to wait one year between pregnancies, and understand that breast feeding increases their need for folic acid. Very young and older women are more susceptible to having children with these defects. Other factors may be involved besides folic acid deficiency but the good news is that folic acid supplementation will likely still reduce these defects.