To work on non-communicable diseases (NCDs) in Africa is to work in a branch of medicine that some have not viewed as a priority for the continent. Shitaye Alemu Balcha, Associate Professor in Internal Medicine in the College of Medicine and Health Sciences of the University of Gondar, Ethiopia, would be happy to enlighten them. Shitaye is a specialist in NCDs, diabetes in particular. “My concern over diabetes…came about because of the difficulties facing poor patients who have to walk long distances to the hospital to collect insulin. It lasts for a very short time, so they have to come back again and again.” Many would end up losing their livelihoods and families, if not their lives.
Neonatal disorders and diarrhoeal and respiratory diseases are the leading causes of death in Ethiopia, but NCDs are on the increase. Accessing treatment is difficult for many people; according to the Ethiopian branch of THET (the Tropical Health and Education Trust), some 85% of people live in rural areas, and almost two-thirds can’t reach a health facility on foot. Shitaye reasoned that if the patients couldn’t get to the hospital, the hospital would have to go to the patients. Her solution was a cluster of outreach clinics. “This [diabetes] is what really drove me. And then, in 1997, I decided that if I go for one disease, why not others as well.” As a result, the clinics for which she’s responsible deal with conditions ranging from epilepsy to asthma to hypertension.
Although Shitaye’s principal concern is with rural health, she herself was born and brought up in Ethiopia’s capital, Addis Ababa, where her father worked in construction. She’s not sure what first aroused her interest in medicine but has a suspicion it was during hospital visits with her parents. “I think I was first drawn to it by the nurses’ uniforms”, she says, chuckling at the absurdity of it. “And even before I went to school, I wanted to become a doctor, and was always playing at being a doctor.” Her parents first supported her, but circumstances changed. “My father died when I was in the 11th grade of school, before I did my matriculation, and when I wanted to go to medical school my mum didn’t like it…She wanted me to do engineering, and follow in my father’s footsteps.” In the end, Shitaye studied at Addis Ababa University School of Medicine, and her mother became reconciled to her daughter’s ambitions.
“My first job was in a general hospital”, she says, “a rural hospital, and I stayed there about 1 year”. In the early 1980s, the newly developed medical school of the University of Gondar was looking for young graduates to start as graduate assistants. “I was recruited as an instructor to teach the students.” Now an Associate Professor, the University of Gondar is still her base. “What’s distinctive about Shitaye is her early recognition of the
problem [of NCDs],” according to Mark Clarfield, Sidonie Hecht Professor of Geriatrics at the Ben-Gurion University of the Negev in Israel. He recently spent a sabbatical with her, and was much impressed by her vision. “She first built services [for NCDs] within the hospital where she works, then built outreach into the community, into rural sites.”
A regular visitor to Gondar is David Phillips, Professor of Endocrine and Metabolic Programming at the University of Southampton, UK. He first encountered Shitaye some years ago during the first of a series of visits to Ethiopia arranged by THET. They now collaborate in research projects on NCDs, including on the cause of diabetes in resource-poor countries. “What Shitaye noticed over many years was an unexpected pattern of disease”, Phillips says. “In the towns in Ethiopia you’ve got the usual rise in type 2 diabetes, but in rural Ethiopia most of the diabetics are type 1.” In rural clinics, he adds, a very high proportion of patients can have this form of the disease. “Is our diabetes malnutrition-related or malnutrition-modified?” Shitaye wonders. Having raised the question, she’s now trying to answer it. “We have a project in which we look for the autoantibodies that are well known in [type 1]
diabetic patients, and also the genes of type 1 patients to find out whether they are similar or not [to those of diabetic patients in richer countries].”
While she values her research, it’s the routine provision of care to people who would otherwise go without that motivates her. The Ethiopian Government, conscious of the increase in NCDs and impressed by Shitaye’s achievements, has created a wider, although still modest, decentralisation programme of its own to deal with them. Workagegnehu Hailu, head of Gondar’s Department of Internal Medicine, describes Shitaye as a good leader. “She’s concerned about society and the health system”, he says. “She loves her subject and what she’s doing… She is passionate, respectful of patients, and humble.” These, he adds, are among the qualities that have made her such a highly acclaimed doctor. “Very sharp clinically”, says Phillips. And wholly committed to her country. “She’s stayed in a small hospital in Ethiopia when a lot of her colleagues have emigrated…and taken advantage of the greater opportunities abroad.” Clarfield too comments
on this: “She’s well connected around the world. With her qualifications and qualities, she could easily have emigrated and got a job with no trouble.” Shitaye’s response is disarmingly straightforward: “I think I am
needed here more than anywhere else.”
Geoff Watts