Transnational Research Associates

Health Profile of

ERITREA

In the Horn of East Africa

Art Madsen, M.Ed.

I Introduction

The East African nation of Eritrea, newly independent after a lengthy and destructive War of Liberation, experienced throughout its pre-Independence history and its brief period of Independence, 1991 to 2000, a wide variety of compelling and destabilizing public health problems. The composition of its population, comprised of nine principal ethic and tribal groupings (Firebrace, Holland, 1985, 32), as well as the peculiar topography of Eritrea, and the country’s widespread impoverishment, have contributed to exacerbation of existing health problems, creating almost insurmountable challenges to the new government of Eritrea.

Relatively few comprehensive, and yet conveniently concise, health profiles of Eritrea exist at the present time. It may prove useful to present key data in an analytical manner, thus affording an opportunity to gain perspective, formulate potential solutions to specific health problems and move the newly independent nation of Eritrea forward in terms of quality of life factors.

By referring to several complicating factors throughout the recent history of Eritrea, namely various obstructions delaying delivery of services, food and relief supplies, the true level of difficulty confronted by the Ministry of Health, logistically and politically, will be clearly seen. These obstructions and dilemmas apply to Eritrea under the Ethiopian Dergue, during the War, and thereafter. In addition to the long-standing suffering of the people, peripheral factors such as needless blockage of assistance will paint a fairly dire picture of progress on the health front in Eritrea during the last 40 years. Indeed, placing all major elements of the health equation in realistic perspective will constitute the main purpose of this report.

It is, therefore, the four-fold purpose of this health profile:

1. to outline the health history of Eritrea at clearly identifiable stages of the nation’s socio-political development;

2. to describe the unique combination of adverse circumstances creating high risk of disease for the nation’s population, inclusive of the types of illness;
3. to summarize the present health infrastructure and the types of disease the system is combating ; and
4. to portray the Ministry of Health’s efforts currently underway to document, prevent and cope with disease and contagion throughout the nation.

The unique geographic and topographic characteristics of Eritrea have historically complicated attempts to stem the spread of disease and illness. The lengthy coastline of Eritrea along the Red Sea is divided into two primary regions, namely the eastern lowlands in the north and the Danakil Desert in the south. This coastal zone represents the country’s longest strip of north-south territory, stretching over 1000 kilometers. In the country’s interior there are highlands extending from the northern border with the Sudan to the militarily sensitive border zone with Ethiopia in the south, a distance of some 400 kilometers. To the west of the central highlands lies an extensive region of lowlands with three prominent rivers, the Barka, the Gash, and the Setit (Firebrace, Holland, 1985, 14). For further clarity, Appendix II provides a pictorial representation of Eritrea’s principal geographic characteristics.

The entire nation would certainly be considered relatively inaccessible from a Western viewpoint, since only a few port cities exist on the coast, and infrastructural assets, such as railroads and highways, have been either destroyed by war or are clearly inadequate. As will be seen later in this report, these factors prevent dissemination of critical health programs, insecticides or medicines, such as vector control operations or vaccination activities (MOH, 1997, 1-2).

II Historical Overview of Disease and Health Care Systems

Eritrea’s contemporary history dates back to 1889 when the Italians first colonized it and defined it as a modern entity, as opposed to the area’s ancient status renowned for its long-lost connections with the Queen of Sheba and King Solomon. Fifty years after their arrival, the Italians numbered approximately 60,000 by the outbreak of Word War II, and had created a fairly sophisticated industrial base for the country. This base included a health care system that catered largely to the colonists’ needs.

During World War II, Eritrea was occupied by the British and the Americans who brought improvements to pre-existing health facilities. This period was followed by a U.N. Mandate, the Ethiopian Government of Haile Selassie, 17 years of cruel domination by the Dergue based in Addis Ababa, a War of Liberation and by the victorious EPLF-associated administration. At each stage of Eritrea’s progress toward Independence, the health care system changed and evolved in ways that will be discussed herein.

The author is fortunate to have at his disposal authentic ministerial publications, bearing the reference-initials "MOH", from Asmara, Eritrea’s capital. They contain facts and figures from reliable in-country sources and represent official statistics presently in use for health planning purposes in Eritrea. Additionally, to provide balance and complete objectivity, other agencies and world bodies will be consulted for data deemed useful in this health profile of the nation.

The health situation in Eritrea, both now and during various historical stages described, is and was quite convoluted, complicated by a lack of verifiable information at certain times, notably under the Selassie and Dergue governments. Nonetheless, EPLF war records consulted show the extent of disease, famine and suffering in Eritrea prior to Independence, as well as portraying recent Ministry efforts to make progress against the major diseases impacting rural areas, with growing implications for urban centers as well (Third World Quarterly, Feb 1999, 129).

Building on information available, it will prove useful, nonetheless, to survey health care since 1889 in Eritrea and then move forward to describe the actual diseases, their relative prevalence, morbidity, mortality and efforts to improve health care throughout the nation.

As indicated briefly above, between 1889 and 2000, there have been six recognizable periods in Eritrean history, each with distinguishing features affecting the health care infrastructure of this emerging nation. Sadly, the story about to be outlined involves the starvation and lingering suffering of millions of people over a hundred years before efficient facilities were placed at the disposal of most of the nation’s citizens.

Under the Italian colonization period extending from 1889 to 1941 when the colonizers were overthrown by Allied Powers in a military surge through the Horn of Africa, the nomadic peoples of the Danakil and the Western Lowland were clearly neglected from a medical standpoint. Also omitted from health care by the Italians were hundreds of remote communities in outlying areas and essentially the entire rural population of the nation, even though a net work of hospitals and clinics coped with many problems. This network was improved under the British, but glaring insufficiencies still existed (Firebrace, Holland, 1985, 103). Most of the rural people suffered from at least rickets and scurvy, plus typhoid, malaria and tuberculosis.

The Italians were more concerned with their own health needs than with the welfare of the subjugated population. Toward the end of the 19^th century, they established the first medical service in Eritrea, based in Asmara, the colonial capital. They set up a hospital there that primarily served early Italian settlers who were prone to various tropical diseases, among them malaria, typhus and typhoid. Wherever there were Italian settlers, clinics sprung up. Where indigenous populations predominated no formally organized health facilities were available (Firebrace, Holland, 1985, 103). Provision under the Italians was made for training of staff at the main hospital in Asmara, but, generally speaking, it seems as if the Italians were neglectful of the long-term health care needs of the nation as a whole.

Later, under the British period of governance, during WW II, and under the post-war UN Mandate, the arguably left-leaning Labour Government in the U.K., at the time, provided funding for an extensive network of clinics and hospitals throughout Eritrea. Many of these facilities were built for purposes of caring for those wounded in fighting, but also served the humanitarian needs of the local population to the (limited) extent that resources permitted.

It might be fair to assert that most of the progress in modern health care in Eritrea was made under the British, even though many of their facilities were rendered inoperative during the subsequent Selassie and Dergue periods. In fact, so drastic were these politically motivated cuts, that in 1965, Haile Selassie reduced the Eritrean health budget by 67% of its 1955 level, already dangerously low (Firebrace, Holland, 1985, 103). This action, actually a ‘cause of war’, decimated any remaining vestiges of civilized health care systems in Eritrea while the region was under the control of Addis Ababa. For decades, disease, famine and hardship abounded. Whole segments of the population, including children, were negatively affected.

During the 30 year War of Liberation that ensued, the Ethiopians destroyed at least 16 hospitals and clinics, uprooted entire populations of agricultural and village workers and spread disease, as well as the risk of disease, wherever they fought in Eritrea Firebrace, Holland, 1985, 104). It is fair to state that health conditions, on balance, deteriorated markedly during the 30-Year War for large segments of the population, particularly in zones occupied by the Ethiopians whose policy was total decimation of all existing facilities. As the EPLF fighting forces captured territory, they established field hospitals and rudimentary clinics which provided services to soldiers, but also to the local population whenever possible.

Nonetheless, disease during the War spread rapidly, with major outbreaks of cholera and typhoid in some areas. These diseases were further complicated by reluctance of the people to accept painful treatments, such as inoculations. They preferred to be treated by traditional ‘magical’ approaches, according to Firebrand and his colleagues (1985, 104).

As temporary government units were established, so were People’s Assemblies that were empowered to formally establish hospitals and health facilities, even as the War continued in nearby provinces and regions. In retrospect, these Assemblies enacted legislation that helped limit the spread and impact of many of the major diseases in areas occupied by the EPLF in the 1980 to 1991 timeframe. Nothing could be done to avoid many of the intentionally inflicted atrocities that occurred during the war, but diseases could be controlled to some degree (Third World Quarterly, 1999, 129)

III Concise Socio-Demographic Profile

Following Independence in May of 1991, and ratification by the world community of Eritrea’s official status of a state, it was possible to proceed with an assessment of the new nation sector by sector (Third World Quarterly, 1999, 129). The National Health Care network was, of course, among those infrastructural assets evaluated by the new Government, along with an assessment of the major diseases and health risks plaguing the country. Table I, below, predicated on relatively reliable WHO, World Bank and UNICEF data, depicts the bleak status of Eritrea seven to nine years after Independence.

Criterion Heading	Statistical Assessment
Life Expectancy at Birth	51 years (M/F)
Infant Mortality per 1000	99
Maternal Mortality per 100,000	1400
Child Malnutrition	25% (1997)
Access to Safe Drinking Water	22%
Access to Sanitation Facilities	13%
Adult Literacy in % of pop above 15 years	20% (1997)
New Telephone Lines (Waiting Time):	10 Years
Telephones per 100 persons	0.9 (1996)

Sources: World Bank, UNICEF, WHO, cited in Health Net Eritrea, Asmara, 1999

TABLE I

Although much progress has been made since the devastating War of Liberation, by comparison with world statistics in each category shown on Table I, Eritrea still ranks among the most destitute and under-equipped nations of the world.

IV Prevalence, Mortality, Morbidity and New Pathogens

The WHO also issues period status reports on immunization programs throughout Eritrea with discouraging percentages for major diseases. The following percentages of infants one year old or less were immunized, for example, against diseases as noted: DPT (46%), polio (46%), measles (38%) and TB (52%), according to WHO data published in their 1998 report. The causes of death in Eritrea involve all of the above diseases, particularly among young children and anemic mothers, plus HIV related viruses and other STDs, disturbingly on the increase. Of the 33.4 million cases of AIDS in the world as of December 1998, 22.5 million of them were reported in Sub-Saharan Africa, of which Eritrea is technically part (World Almanac, 2000). However, the prevalence of STD’s is not easily estimated in Eritrea due to reluctance to talk openly about it on the part of the population. Nonetheless, awareness of AIDS is particularly high and it is statistically noted in Ministry of Health records that 82.1 percent of all Eritreans aged 15 to 19 have, at least, heard of AIDS (MOH, 1995, 143). Figures of this nature abound in Ministry documentation; so assumptions as to the impact of AIDS and HIV throughout Eritrea can be validly derived. Appendix I displays additional figures on HIV and AIDS in Eritrea. Both of these inter-related conditions represent significant threats to the population, although in Ethiopia, Eritrea’s enemy state to the south, HIV/AIDS rates are even higher (ABC News, April 2000).

Key data pertaining to the prevalence and ranking of major diseases might be useful in determining where the Government should place priority funding for alleviation of these destabilizing conditions. Drawing information from a variety of sources, Table II, below, itemizes four primary vector-borne or diarrheal risks affecting Eritrea in recent years. The ranking presented below, featuring "malaria" as the most prevalent condition, has been excerpted from Ministry of Health statistics in Eritrea and is considered valid. Beyond these major illnesses, other primary causes of death and debilitation are classified as communicable in nature and are listed on Table IV further on in this report.

Malaria	Cases Treated Jan-Jun 1998: 121,899
Gastro-Enteritis	Various Forms Prevalent in Rural Areas, plus the two major forms below.
Amoebaiasis	Also a G-I Infection: Waterborne in Outlying Western Areas
Helmintaiasis	Another G-I ailment: Judged Serious throughout the Nation

Source: MOH, 1997, 1998

TABLE II

Tragically, there have been a great number of needless deaths in Eritrea, as alluded to in our introductory passages, related to logistical delays and political obstructions, some occurring even subsequent to completion of the War of Liberation. However, some of the recent literature is suggesting that new success is being achieved among relief agencies that have finally learned how to coordinate delivery of vital supplies even in remote regions, handicapped by war-decimated rail lines and poor road conditions. International food donors, non-governmental organizations and the EPLF’s own relief operations (known by their acronyms as the "ERA" and the "REST") have been stepping up shipments of food and medical supplies to remote areas in recent years, as they did to a lesser degree during the War. Refugee populations have been resettled for the most part and this, in itself, has also lowered the rate of infection and cross-infection among contagious conditions. General aging of the working-class population (52% over the age of 50) is leading to labor shortages in vital industries and this also impacts public health on a broad scale directly and indirectly. The young cannot care for themselves and society at large is under-prepared to come to their assistance financially or medically.

In addition to the health and demographic trends noted above, there have been high numbers of new pathogens on the scene in recent years, related to poor sanitation, inadequate water systems and the absence of vector control programs. Ministry of Health documentation attests to these new developments in a variety of publications, referred to in the Reference Section and on Tables I and II.

Women have borne a disproportionate percentage of the poor-health burden in Eritrea, both previously and at the current time. As if nature itself were not sufficiently cruel to Eritrean women, their own society inflicts additional burdens upon them. 90 to 97% of all women ages 15 to 49, are circumcised with 60% of those subjected to circumcision receiving a clitoridectomy and 33% undergoing complete infibulation (National Statistics, 1997, 165-166). Such procedures can lead, directly or indirectly, to pelvic bone deformation during and prior to labor and birth. Additionally, infibulation can cause retention of urine, promoting a variety of kidney and bladder problems for which treatment is not always practical or available in Eritrea.

In spite of culturally imposed restraints on sexual behavior of females, there has been a steady increase among both sexes in STDs with special reference to AIDS and HIV. In fact, a newly conceived division within the Health Ministry has been created to deal with ever-mounting STD figures.

Prostitution during the war contributed to moral decay and, consequentially, a steep rise in the incidence of HIV among women was immediately discernable. Some progress has been made in abatement of the problem during post-war years.

Appendix I denotes cases of AIDS reported to major hospitals in large centers throughout Eritrea. Women were found to be infected disproportionately to males -- in fact, 18 to 1 in the 15 to 19 age-group. Revealingly, the Eritrean Health Ministry’s report also indicates that 72% of women infected with AIDS are housewives, more than any other category of female (EMH, 1998). The unemployed, both male and female, are also heavily impacted, the cited report confirms.

The economic implications of female AIDS are significant. The Government must spend funds to care for infected mothers and their children. Agriculture and industry are adversely affected, due to loss of the female’s important contribution to these two economic sectors.

Age Group	Percent of Eritrean Women With No Education
25-29	71.4
30-34	79.0
35-39	77.3
40-44	84.7
45-49	90.0

Source: Eritrean Health Ministry, 1998

TABLE III

As can be seen on the preceding Table, from an educational standpoint, women are in dire straits throughout the entire country; rural, coastal and urban areas are equally affected by the disturbing nature of most educational statistics. Naturally, due to an uneducated person’s inability to adapt to society’s many demands, there is a correlation between poor educational background and resultant poor health and/or psychological instability.

V The Current Health Infrastructure in Eritrea

Following the War of Liberation, more than 500,000 refugees who had fled to the Sudan had to be repatriated over a three-year period. Resources were finite and had to be scaled down on a per refugee basis, to levels much lower than was the case elsewhere in Africa. About one eighth of the funding requested was actually available. This eighth amounted to $32 million and represented the beginning point for the restructuring of the state (Third World Quarterly, 1999, 129ff).

Decisions had to be made as to how reconstruction of the country and its health infrastructure was going to be implemented. A macro-economic model was selected with revenue from exports ostensibly fueling growth. Funds from exports could be used, it was felt by the ruling PFJD party to rebuild hospitals and clinics for the population nationwide.

Thanks to World Bank Financing, export revenue and donor-generated funds, Eritrea now has a total of 252 health care facilities (World Bank, 1997; MOH, 1998).

Table IV, below, indicates the location of these hospitals and clinics, their number, and the percentage of them that reported communicable diseases to the capital, Asmara, in June of 1998. The low percentage of clinics and hospitals reporting periodically is definitely cause for concern, and seems due to improperly trained or poorly motivated personnel staffing them. This Table also portrays Eritrea’s leading communicable diseases, in descending order of importance, as reported by all clinics and hospitals in 1998 throughout the nation.

Geographic Region	Total Number of Health Facilities Per Region	Percentage of Facilities Reporting per Region	Leading Reported Communicable Diseases
S.R.S.	15	80	Malaria
N.R.S.	40	15	Pulmonary TB
Gash-Barka	54	15	Diarrhea
Debub	51	22	Gonorrhea
Maekel	60	13	Schistosomiasis
Anseba	32	81	Gastro-Intestinal
TOTAL	252	28	---------

Source: Eritrean Ministry of Health, 1998.

Table IV

It is generally acknowledged by these 252 health facilities throughout the nation that the prevalence of malaria and pulmonary tuberculosis, plus diarrheal conditions, is an operant factor in the destabilization of families, communities and the local economy.

VI Socio-Political Observations and Concluding Remarks

Four fifths of rural women, as we have seen, have not attended school at all, whereas in urban areas their average educational attainment is 2.7 years, with only one year more, on average, in Asmara. Two thirds of men in Eritrea have no education at all. These are dire indicators of the socio-economic status of the entire nation, adversely affecting awareness of disease, its communicability and simple measures of prevention. (DHS, 1995, 15)

Transportation constraints, great distances and non-availability of health facilities all contribute to massive gaps in nationwide health care, even after nine years of independence, reconstruction efforts and international loans.

Although immunization programs have proven partly successful, only 22% of families live within four kilometers of basic malaria-treatment or general health care centers (DHS, 1995, 191). Coupled with other aggravating factors, such as a shortage of nutritional foods, these conditions have led to serious stagnation in development of adequate health and hygiene programs across the country.

The Government must assign urgent priority to the treatment of endemic conditions, such as malaria and pulmonary tuberculosis, and must strive to continue building the national communication system, the transport network and the health infrastructure in order to prevent the many thousands of unnecessary deaths that are reported each year.

VII REFERENCES

……….., ABC Newswire Report, "Ethiopia Steps Up Fight Against AIDS", April 23, 2000. http://www.abcnews.go.com/wire/World/reuters20000423_146.html

Asfeha, E., Six Months Report of Notifiable Communicable Diseases (Jan- June 30, 1998), CDC, Ministry of Health, Asmara, 1998.

Barker, A., Eritrea 1941, Faber and Faber, Ltd., London, U.K., 1966.

Filli, S.F., National Immunization Days: Report 1997, with Annexes, Asmara, December 1997.

Firebrace, J. and Holland, S. Never Kneel Down: Drought, Development and Liberation in Eritrea, The Red Sea Press, Trenton, N.J., 1985.

Ghermazien, T., National Environmental Management Plan – Eritrea, Ministry of Agriculture, Asmara, 1995.

Hervey, C., "World Bank Approves 18.3 Million Loan to Improve Health Care in Eritrea", World Bank Press Release, Washington, D.C., Release No. 98/1583AFR December 17, 1997. http://www.worldbank.org/html/extdr/1583.htm

International Planned Parenthood Federation, Country Profile – Eritrea, New York, N.Y. 2000. http://www.ippf.org/regions/countries/eri/index.htm

M’Bendi African Resource Network , Eritrea, Lusaka, Zambia, 2000 http://www.mbendi.co.za/cyercy.htm

Ministry of Health, EPI Plan of Action 1998, Asmara, 1998.

Ministry of Health, National HIV/AIDS Policy, Asmara, December 1997.

Ministry of Health, National Tuberculosis Control Programme (NTCP), Notification and Other Activities, Jan – April 1998, Asmara, 1998.

National Statistics Office, Fact Sheet - Eritrea, 1995, Macro International Inc, Calverton, Maryland.

National Statistics Office, Eritrea Demographic and Health Survey, 1995, Office of the President of Eritrea, Macro International, Inc., Calverton, Maryland, March 1997.

N’Hafash, A., Tewelde-Meskel, G., Annual Report of Malaria Control Programme, 1997, CDC, Ministry of Health, Asmara, March 30, 1998.

Opportunities for Micronutrient Interventions, "OMNI Programs in Africa", 1999., Eritrean Page http://www.jsi.com/intl/omni/up_1_98.htm

Rock, J., "Relief and Rehabilitation in Eritrea: Lessons and Issues", Third World Quarterly, London, Feb 1999, 129-142.

Statistical Yearbook/Annuaire Statistique, "Health and Child-Bearing", New York, 1997, 103.

Tesfu, I. Asmara Environmental Management: Asmara Planning Forum, Dept. of Environment, Ministry of Land, Water and Environment, Asmara, June 1997.

Tewelde-Meskel, G., "Six Months Report on Malaria Control Activities (Jan. 1, 1998 to June 30, 1998)", Ministry of Health, The State of Eritrea, Asmara, issued July 7, 1998.

Tesfamichael, N., Six Months Report of National AIDS Control Program Unit, Asmara, July 29, 1998.

U.S.A.I.D. "Congressional Presentation, FY 1998 ERITREA Program Summary", Washington, D.C., 1998. http://www.info.usaid.gov/pubs/cp98/afr/countries/er.htm

U.S.A.I.D. Eritrea Country Achievement Summary: Basic Support for Institutionalizing Child Survival, Washington, D.C., 1995-98.http://www.basics.org/summaries/Eritrea.htm

U.S. Department of State, Background Notes: Eritrea, Washington, D.C., March 1998.

U.S. Department of State, Post Report 1996 Eritrea, Washington, D.C., July 1996.

U.S. Mission to Eritrea, Asmara, Eritrea, 1999. http://usembassy.state.gov/eritrea/

World Almanac and Book of Facts: 2000, UN-AIDS, "Joint UN Program on AIDS", New York, N.Y., 1999, 880.

World Health Organization, World Health Report 1998, WHO, Geneva, 1998.

http://www.healthnet.org/hnet/eri.html

………….. "1998 World Health Statistics", World Health Organization, Geneva, 1998

APPENDIX I

AIDS and HIV are on the increase in Eritrea as documented in numerous publications. The figures shown on the below Table reflect only those cases reported to hospitals, and represent a small percentage of AIDS cases in Eritrea for the six-month period in question. There are sixteen reporting hospitals, of which the top 5 are noted below. The remaining eleven hospitals recorded additional cases bringing the 6-month total to 713 reported cases, as can be seen.

Cases of AIDS/HIV Reported to Major Eritrean Hospitals

January to June 1998

Top 5 Hospitals Reporting: Jan-June 1998	Number of Victims Reporting
Halibet	483
Adi-Keih	42
Massawa	36
Mendefera	34
Edaga Hamus	23
Remaining Eleven Hospitals	95
TOTAL Cases Reported	713

(Source: MOH, July 1998, 29)

Unlike in Western countries, far more women are affected by AIDS in Eritrea; in fact the ratio is 18:1 in the 15 to 19 age-range. However, additional figures show that the economically productive age-range is most heavily affected.

APPENDIX II

Map of the State of Eritrea