Camels can’t be put on motorbikes

Adoy Sheik Oumer is 42 years old and mother of eight children. She lives in Arda Ola in the Somali region of south-eastern Ethiopia. The nearest major town Moyale, which has a health centre with qualified medical staff, is about 20km away. Until recently, when one of her children had severe stomach cramps or was bitten by a potentially rabid dog or contracted a life-threatening infection from an injury, she had to be taken to the health centre on a motorbike via a potholed track.

The return journey cost USD 8 which is a lot of money for a herder in Ethiopia. However, these are times of the past. Since 2020, health workers supported by the NGO Vétérinaires sans Frontières Suisse (VSF Suisse) regularly visit Arda Ola. Oumer and her village are especially pleased that they can also bring along their sick camels, goats and cattle to be examined and treated at the mobile health centre.

Over 30 million people live as pastoralists and agropastoralists in the Horn of Africa. The latter do not just herd camels, cows, goats and sheep across grazing pastures but also cultivate grain, vegetables and fodder. The communities who live in the border region between Ethiopia, Kenya and Somalia share close cultural links. National boundaries are of little significance in their nomadic lifestyle. What is common to them all is that their survival and income depend directly on the health of their animals. They consequently live in very close quarters with the animals making them highly vulnerable to zoonoses, which are infectious diseases that are transmitted from animals to humans (see box).

"The pastoralists in all three countries are population groups with the poorest access to health services," says Metalign Ayehu, the programme lead for VSF Suisse. From his office in Ethiopia’s capital Addis Ababa he leads the trinational One Health project OH4HEAL (see box) which is co-funded by the SDC.

One major stumbling block are the distances. Health centres and veterinary services are sometimes located 40km away from the communities while hospitals are often even farther away. Transportation is scarce and the roads are often in poor condition. "It was clear to us from the outset that the beneficiaries would need to be closely involved in planning our project and that we would need to be innovative to deliver health services to communities at their doorstep," says Ayehu.

The first step was to set up Multi-Stakeholder Innovation Platforms (MSIPs). The members of such platforms include village elders, women’s groups, youth representatives, women farmers, religious leaders and health workers. They meet once a month and discuss how the community can improve the health of people and animals, e.g. by building public latrines, renovating a dilapidated health centre or growing fodder for the animals. So far, 27 such MSIPs have been established in the area covered by the project. Ayehu is proud that over 40% of the MSIP members are women. "We aim for 50%."

Die zweite zentrale Innovation sind die vom Projekt initiierten «One Health Units» (OHUs). «In diesen Einheiten führen wir die Gesundheitsdienste für Tiere, Menschen und Umwelt im Sinne einer "One Health" zusammen.» Staatliches Gesundheitspersonal für Human- und Tiermedizin arbeiten dort Hand in Hand und werden geschult durch Mitarbeitende von VSF Suisse oder weitere an «OH4HEAL» beteiligte NGOs. Je nach lokalen Gegebenheiten sind die OHUs fix in einem Gebäude installiert oder mobil, damit sie den Pastoralisten auf ihren Weiderouten folgen können.

The second key innovation has been the One Health Units (OHUs) piloted by the project. "We integrate health services for animals, humans and the environment in these units in line with a One Health approach." Government health staff for human and veterinary medicine work hand in hand and are trained by VSF employees or other NGOs participating in OH4HEAL. Local conditions determine whether the OHUs are static and installed in a building or mobile and able to follow the herders on their grazing routes.

There are also hybrid OHUs that have static locations but also mobile teams that visit far-flung communities, such as Oumer’s in Ethiopia’s Arda Ola. In Somalia, on the other hand, it would currently be too dangerous for health workers to drive out to different communities. Armed groups are active in these areas and attacks occur frequently. Two static OHUs have therefore been installed in Gedo, in the southern part of the country. "The population now knows where to find us even if access is extremely difficult," says Ayehu.

Anthony Odhiambo is a doctor working for Amref Health Africa, an NGO based in Nairobi which is part of the OH4HEAL consortium. He manages project activities in Kenya. Six mobile OHUs are active in Marsabit and Isiolo near the Ethiopian border. These are off-road vehicles equipped with medicines, vaccines and other essential supplies. The team includes at least one driver, one health expert for animals and one for humans and, if available, an agricultural expert. "Some communities are over 100km apart," says Odhiambo. "The teams generally stay overnight, vaccinate and treat sick animals and people the next morning and then continue to the next community."

Since human and veterinary doctors travel together and coordinate amongst themselves, the resulting synergies can be utilised to reduce costs for transportation and logistics. Mobile healthcare services also provide an incentive for people who bring in their animals for treatment or vaccination and get their families checked up. "Otherwise, people go to the doctor when it is already too late," says Odhiambo.

This is also a cultural issue. Pastoralist communities in the Horn of Africa believe that people’s health is in God’s hands while people are responsible for the health of animals. For this reason – and also because animals are essential for feeding their families – many pastoralists are much more concerned about the health of their animals than their own.

Odhiambo mentions a further advantage of mobile OHUs. Outbreaks of zoonotic diseases are now detected earlier than before. Marsabit and Isiolo witness recurring outbreaks of rabies, Rift Valley fever, leishmaniasis, anthrax and brucellosis, with brucellosis being the most frequent. Sick camels, cattle, goats and sheep transmit the infection to their owners. The main symptom is fever which often comes with chills and nausea. Vaccines for animals do exist but are usually not available in remote regions.

Whenever brucellosis outbreaks occur in the region now, the veterinarians inform their OHU colleagues about it, who in turn warn the communities and advise them, for example to boil the animals’ milk to kill the pathogens and prevent infection. The main mode of transmission is unpasteurised milk. "Small behavioural changes are often the best prevention," says Odhiambo. But in this case change requires time as many pastoralist communities firmly believe that fresh camel milk is better and healthier than boiled milk.

People in the Horn of Africa are affected by zoonotic diseases particularly frequently. At the same time, they are also most impacted by the climate crisis. "In the regions where we work, it hasn’t rained for five seasons in a row," says Odhiambo. When he visited the project partners in Marsabit in May, he saw skeletons of animals which had died of dehydration lying around everywhere.

An estimated 75% of livestock have perished due to the drought. The number of malnourished children has also increased in the past few years. People in the Horn of Africa are adept at dealing with droughts; they have learned to live with them over centuries. "However, the elders now say that the weather is more unpredictable. Droughts that used to occur at intervals of 10 years are now much more frequent."

It is difficult to make specific weather and climate predictions for the dry region between Somalia, Kenya and Ethiopia. Existing meteorological stations are often hundreds of kilometres apart, and there are no historical meteorological data. The project consequently joined hands with Kenya's meteorological department to set up 13 basic weather stations in Marsabit and Isiolo. Trained staff in the OHUs measure precipitation and maximum temperatures daily and enter them in a table. Once a week, the data is uploaded through an app for evaluation by an expert in Italy who has been commissioned for this purpose.

The communities discuss the results locally with experts from the meteorological department. "Our aim is to combine traditional and local knowledge about climate with scientific inputs from meteorologists," says Odhiambo. This basic information helps to better adapt grazing routes to hot weather and water availability. It also allows agropastoralists to sow suitable crops at the right time.

The first four-year phase of OH4HEAL is due to end in 2024 and is to be followed by two further project phases until 2032. "Our medium-term goal is to scale up the OHU model across the entire region. We aim to do this in close cooperation with the government," says Ayehu from VSF Suisse in Ethiopia. "Our intention is not to create structures operating in parallel to the public health system." The One Health units should become an integral part of the national health system. To achieve this, One Health task forces were established at the district level. They include government agencies responsible for health, the environment, animal welfare and agriculture. Any issues related to public health service delivery are jointly discussed.

There is evident commitment by the governments to the One Health approach, says Ayehu. Ethiopia has had a national One Health committee for several years. In Kenya, a Zoonotic Diseases Unit (ZDU) was set up in 2011 which comprises both veterinary and human medicine doctors. Even in Somalia there is a One Health nodal officer at the national level, but there is a dearth of capacities and reliable planning due to the grave security situation. The project has nevertheless been very well received by local authorities at the district level.

Currently, the biggest obstacles to scaling up the OHUs are a lack of funding and the effects of the drought. While it has rained again in the last few months which has created more grassland, most families have been severely weakened and have practically no animals left. "The concerned authorities have said that they can no longer invest in One Health because all funds have been allocated to emergency drought relief," says Ayehu. In 2022 and 2023, the project was able to mobilise a total of CHF 890,000 in emergency assistance through an SDC crisis fund and could thus support people with direct payments and bought animal feed.

Some MSIPs have also begun to build simple hydroponic systems made of used materials to grow their own fodder. These use no soil and very little re-circulated water. "It's very promising," says Ayehu. "We can harvest 7kg of fodder from 1kg of seeds in a week and need only 3 litres of water." The pilot will soon be implemented in several communities.

Despite the frustrations and enormous challenges, Ayehu is convinced that OH4HEAL is on the right track. This has been created by feedback from the communities, for instance from Oumer in Arda Ola. During Ayehu's last visit, she told him that for the first time pregnant women receive medical treatment locally and no longer have to undertake the arduous journey. More importantly, their animals also receive better care. Unlike a sick woman or child, one can't simply put a sick camel to the nearest health centre on a motorbike.