Date: Sunday, 06 May 2018
Amahazion, Fikrejesus, PhD1
Kidney transplantation is the treatment of choice for end-stage renal disease (ESRD). Transplantation has been “hailed as one of the great miracles of modern science,” and celebrated as “one of the major accomplishments of the twentieth century.”1,2 The availability of dialysis and kidney transplantation, however, has been unequivocally lower in Africa compared with other regions of the world.3
Eritrea is a young, low-income country located within the Horn of Africa region (Figure 1). After battling one of the longest liberation wars, the country eventually gained independence in 1991. Eritrea spans over an area of approximately 124 000 km2, divided into 6 main political administrative regions (referred to as zobas): Debub, Gash Barka, Maekel, Southern Red Sea, Northern Red Sea, and Anseba. Eritrea has a population of approximately 3.5 million people belonging to 9 separate ethnolinguistic groups; the country's per-capita GDP is approximately US $700. The population of Eritrea is split almost evenly between Christianity and Islam.4-6
Notably, Eritrea has made commendable progress within the health sector based on the United Nations Millennium Development Goals: life expectancy has increased (from 48 years at birth in 1990 to over 67 in 2013), whereas maternal, infant, and child mortality rates have been reduced dramatically (now approximately 280 deaths per 100 000 births, 41 per 1000 births, and 16 per 1000 births, respectively); immunization coverage has rocketed (polio has been eradicated and DTP3 coverage is now about 98%, as compared with 10% in 1991); malaria mortality and morbidity have plummeted; and human immunodeficiency virus prevalence is quite low (less than 1%).7-10 Although representing considerable progress, the country continues to face significant challenges, including poverty (in 2005, the proportion of the population living below the national poverty line was estimated at approximately 66%, with the vast majority, approximately 67%, living in rural areas), an insufficient infrastructure, food insecurity, limited skilled labor, macroeconomic imbalances, regional conflicts and instability, international sanctions, and geographic challenges with erratic rainfalls and severe droughts.4,6–8,11,12
Eritrea aims to achieve equity and access to essential health services at an affordable cost. Priorities include addressing maternal and child healthcare and the control of communicable diseases. Health services are delivered based on 3 tiers with primary-level facilities (health stations and health centers), secondary-level facilities (first contact or subzone hospitals and zonal referral hospitals), and tertiary-level facilities (national referral hospitals). In accordance with government policies, there are no independent private health facilities in the country, although there is a system of private practices within government health facilities.8,10,13
As a young, low-income, developing country, Eritrea faces numerous challenges within its healthcare system. Specifically, the country has deficits in health financing, access to basic technologies and medicines, and medical information systems, whereas lacking a skilled health workforce necessary for combating noncommunicable diseases. Furthermore, healthcare workers often have a heavy workload related to a high patient to doctor ratio (which, at approximately 0.5 per 10 000 people, is slightly less than the Sub-Saharan Africa (SSA) regional average). Considerable investments including educating and training physicians and medical staff through establishing medical, dental, and health sciences facilities and schools, developing linkages with foreign partners, and expanding access to foreign scholarships and distance learning are currently being made. Notably, Eritrea also has dedicated and committed staff in primary healthcare.14
In Eritrea, as in other countries of SSA, robust epidemiological studies are frequently lacking.15 Therefore, data of chronic kidney disease (CKD) and ESRD, including risk factors, such as diabetes mellitus and hypertension, remain scarce. Moreover, with Eritrea's general improvements in healthcare, chronic diseases are on the rise. Chronic diseases are not only important public health issues but also have significant economic consequences leaving families in poverty and burdening healthcare systems.
Diabetes mellitus is one of the leading causes of morbidity and mortality of adults in Eritrea. Recent estimates suggest a national prevalence of approximately 3.06% (whereas the average for SSA is about 4%). A total of 78 686 new cases and 926 deaths related to the condition were reported between 1998 and 2013, and diabetes mellitus accounted for 2.7% of total reported deaths in 2013. Not only has the incidence of diabetes risen in the country, there is also an increasing amount of disabilities linked to amputations, as well as diabetic retinopathy and blindess.10,16,17
Relevant risk factors associated with the growth of diabetes in Eritrea include slowly changing dietary habits, such as augmented food quantities, the introduction and consumption of refined, processed or fast foods and high salt intake, in addition to growing urbanization with reduced physical activity and a shift toward sedentary lifestyles or occupations for many.
Hypertension, a strong independent risk factor for CKD and ESRD represents an additional health challenge within Eritrea.10,14,18 The prevalence of hypertension (BP > 140/90 mm Hg) has been 15.9% within the general population (16.4% in urban and 14.5% in rural areas, with 17% in males and 15% in females)19; 54 hypertension-related deaths were reported in 2013.16
Although the incidence of diabetes and hypertension is on the rise in Eritrea, specific rates for CKD and ESRD remain unknown.7,10 It is probable that rates of CKD and ESRD in Eritrea may exceed those in developed countries based on a high prevalence of undetected hypertension, diabetes, and human immunodeficiency virus–related nephropathies. Moreover, a more rapid progression to ESRD can be assumed with a limited capacity to address relevant risk factors.3
Dialysis treatment was introduced in Eritrea in 2008 at Orotta Referral Hospital in Asmara, the capital, supported by international partners. Those efforts initially installed 4 dialysis machines (with 2 put in reserve). In 2015, the Ministry of Health opened an additional dialysis center at Sembel Hospital, also in the capital. Currently, both dialysis centers, which extend services to patients free of charge, run 28 dialysis machines (14 at each center). However, with both centers located in the capital, patients in other parts of country face significant challenges accessing those centers. It is important to recognize that approximately 3 million people die each year due to lack of access to dialysis across SSA (whereas the entire population of SSA is approximately 1 billion).20
Transplantation services are currently not available in Eritrea. Significant barriers to initiating a transplantation program include a shortage of qualified health professionals, infrastructure, and resource deficits. Moreover, the country prioritizes public health fundamentals, such as clean water, sanitation, vaccination, and communicable diseases. Although some Eritreans may travel abroad for various medical services, data about those traveling for transplantation are unknown. Generally, these activities are privately funded (as opposed to official arrangements where governments send citizens abroad to receive services). With Eritrea being a low-income country, these activities are essentially restricted to those few who have the means to travel abroad. In general, both in Africa and many other regions of the world, challenges arising for patients traveling abroad are the continued provision of immunosuppressive medicines and follow-up care.
In recent years, many migrants and refugees from across Africa, including significant numbers from the Horn of Africa and Eritrea, have travelled through Libya, Sudan, Egypt, and the Sinai region seeking to escape conflict, political turmoil, hunger, and poverty and hoping to reach Europe. Many have fallen victim to human trafficking, violence, and death. Although bodies have been found in mass graves or in desert areas badly disfigured and missing vital organs, little reliable data exist to help provide a more comprehensive understanding of the dimensions, extent, and reach of organ trafficking because the entire process is an underground, clandestine criminal activity.
Based on the rapid increase of risk factors linked to CKD, Eritrea will likely experience an increased demand for kidney transplantation. More and robust population-based studies and data collection are necessary to estimate the prevalence of ESRD and its risk factors providing critically relevant information for government and policymakers.
Additional and geographically distributed dialysis centers will need to be established. Furthermore, although hypertension management services are more accessible, greater access in rural and remote locations needs to be provided.
There is a considerable need to increase public awareness about kidney diseases and associated risk factors in Eritrea. Those efforts may potentially be linked to existing government and community-based programs offering information on general health issues (such as safe-sex education and antismoking campaigns). In recent years, large public awareness campaigns involving the Eritrean National Diabetes Association have been conducted. Moreover, health campaigns can use media outlets and general communication opportunities. With Eritrea being an ethnically diverse, multilingual country, it is important that educational and awareness materials or resources are translated into all languages used within the country while various communities should be involved in design and dissemination.
A lack of skilled health specialists remains a major challenge. Developing regional or global partnerships may thus help improve renal replacement therapy in the country. Neighboring Sudan or South Africa, which both have supportive bilateral relations with Eritrea may provide cooperative assistance to local clinicians. South Africa is the only country in SSA offering both living and deceased donor kidney transplantation, whereas Sudan has one of the highest regional rates of organ transplantation relative to its population.3
International societies and global organizations including the World Health Organization may provide additional support advancing renal replacement therapies. A living donor kidney transplant program appears as a first pragmatic step. Not only does transplantation improve quality of life and provide better outcomes for patients than other treatments for ESRD, it will reduce existing pressures on the country’s limited dialysis facilities, and is also considerably cheaper and more cost-effective in the long run—an important consideration for a low-income country, such as Eritrea.
Commencing a transplantation program in the country requires the establishment or significant upgrading of considerable infrastructure and facilities. Comprehensive postoperative follow-up care facilities and supportive services are also vital to monitor renal function and address potential complications while promoting long-term posttransplant well-being.
The establishment of a transplant program is predicated on the availability of a multidisciplinary team and skilled personnel. To help confirm expertise, surgeons and physicians should be encouraged to shadow or train abroad (in fellowships, courses, or clinical training opportunities). Experienced foreign personnel and experts can be consulted to share good practices and expertise, guide, oversee, and monitor the program, support skill transfer (eg conducting courses or workshops), and mentor or advise local personnel. The new program could also look to other transplant programs, including those from the surrounding region or other low-resource settings (eg, South Africa, Sudan, North Africa, and Southeast Asia) for implementable lessons and potential challenges.
Strong support and leadership by government, hospital administration, and other entities (eg, nongovernmental, charity, private, professional associations or societies, and other international entities) is necessary to establish an effective ethical and regulatory framework. For example, policies regarding donation could outline criteria for informed consent from a competent person, free of undue influence, pressure, and commercialization.
Another important aspect is the formation of a central renal registry and comprehensive data collection on transplantation activity, CKD, and ESRD. The publication and dissemination of activity and outcomes should also be encouraged to share best practices, lessons learned, and challenges.
With transplantation representing a new concept within the society, it will be critical to provide relevant information, dispel myths or misconceptions, encourage donations, and address potential social or cultural barriers.
The author would like to thank the Department of Sociology and Social Work at the College of Arts and Social Sciences (Adi Keih, Eritrea) for their considerable support. Additionally, the author would like to thank the numerous individuals, organizations, and ministries in Eritrea that contributed their time. Feedback, suggestions, and guidance from editors (Stefan G. Tullius) and reviewers have been especially helpful and are highly appreciated.