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POVERTY, THE BANE OF POOR HEALTH IN SUB- SAHARAN AFRICA;
EDO STATE OF NIGERIA AS A REFERENCE.
DR STEPHEN E.O.OGBONMWAN M.MED, MFFP, MRCOG (UK), FMCOG .
SPECIALIST OBSTETRICIAN & GYNAECOLOGIST.
EDO OKPAMAKHIN ANNUAL CONVENTION JULY 2004.
HOLIDAY INN, LOGAN AIRPORT, BOSTON, MASSACHUSETTS, USA.
I would like to thank the organisers of this convention for this opportunity to share my thoughts on the issue of health services and the state of health of the people of Edo State so that we may proffer solutions on how the situation can be improved. As there is more than one speaker dealing with the issue of health, I would try to limit myself to the health of women and children and occasionally dabble into health for all.
The WHO's Constitution defined health as
a state of complete physical, mental
Let us limit ourselves to the aspect that stated �� social wellbeing�� What is social wellbeing?
The synonyms for social include collective, shared, communal, community, societal and common. Whereas the synonyms for wellbeing include security, safety, health, comfort and happiness.
Social wellbeing therefore implies collective, communal or community safety or security or health or comfort. You know, and I know and we all know that these are rare features amongst our people especially our women and children in Edo State and Nigeria.
Good health is a major resource for social, economic and personal development and an important dimension of quality of life. Good health can be favoured by political and economic policies, social, cultural, environmental, as well as behavioural and biological factors.
The reverse is also true. If economic, social and political policies are poorly implemented or non implementation can be harmful to peoples� health. The numerous civil wars in sub-Saharan Africa, poor governance of the people, selfish and inoperable governmental policies, non payment of salaries all add to the woes of the poor state of health of our people.
The Health Woes
To see how poor in health we are, compare the actuarial calculation of life expectancy for Nigeria, which is 48 years with that of the UK, which is 81 and 84 for the women. Yet we are living in the same world. Are we really?
MATERNITY CARE AND DEATH IN INFANCY.
The fertility rate in Nigeria is 6.4 one of the highest in the world but note that nearly fifty percent of the children will die before their 5th birthday. That is colossal loss of human lives. It is only in sub-Saharan Africa you will hear of women who have been pregnant 17 times, has had eleven babies with only two children alive. She is not only psychologically traumatised due to the loss of her babies from poor and inadequate health services in addition to her lack of proper education, her blood level will be low, her womb is likely to be dropping down from below, she is likely to wet herself when she passes urine, and she is completely washed from breast feeding her babies and looking after her husband. If she is unlucky to be leaking urine continuously then she will be a social outcast. This is the picture of the extreme of the spectrum for some of the women, but in this desert of abject poverty and wants, there are oasis of affluence where women can afford to come to Europe to have their babies in the best maternity units that Europe can provide.
When you compare the neonatal mortality rate of 105 per thousand live births in Nigeria (UBTH 33/1000 in 1987) with that of the UK where the neonatal mortality is 8/1000 live births you will not blame these women. The cost of flight of a pregnant woman and her husband flying from Abuja to London is five hundred thousand (500,000) naira, the delivery cost is about six hundred thousand (600,000) naira equivalent in the local currency and if a caesarean section is done, the cost will increase to about eight hundred thousand (800,000) naira. When you add the husband�s hotel bills as she can not stay in the wife�s room in the maternity unit and other incidentals, the total cost will be about four million naira using a conversion factor of 250naira to one pound. This huge amount can build or equip a maternity unit in Benin with basic equipments or better still pay the salaries of over 80 midwives for one year. Think of the number of people that amount of money can feed in a year in Nigeria. You can see it is not only the government that is to blame but we the people as well. We need to set our priorities right. We need to throw away the concept of I and start thinking of �us or we�
In sub-Saharan Africa the maternal mortality rate (number of women who die in childbirth) is 920 per 100,000 live births. Compare to 24 per 100,000 in Europe. You will see the colossal waste of human lives? The total number of maternal deaths in Nigeria in the year 2000 was 37,000. Nigeria came second in the whole world to India with 167,000 maternal deaths, but note that the population of India is over one billion people. If the figure is adjusted for population then Nigeria will have the highest maternal death per population in the whole world. These women do not come from outer space. They are our wives, your sisters, our mothers. This is a huge problem the government does not want people to know about.
What about the woes from unsafe abortions by which I mean abortion not provided through approved facilities and/or persons" This is classified as illegal abortions in Nigeria. As abortion is not legalised, there is a thriving back room, backdoor and backstreet abortions in the population. Death from illegal abortions accounted for 13% of the total maternal deaths in Nigeria in the year 2000. This percentage translated into 4800 deaths amongst our daughters and wives in Nigeria in the year 2000. You will all agree that a lot of the deaths will go unrecorded. So this number of deaths is actually the tip of the iceberg as it is a more serious problem. What about those that are maimed for life, what about those that will never be able to fulfil the normal biological process of pregnancy, labour and delivery as a result of the sequelae due to procuring illegal abortions. The psychological trauma and abnormal grief reaction in such women can only be imagined The list of woes is endless.
ILL HEALTH AND DEATHS FROM ARMED ROBBERY.
Social wellbeing equates to safety and security of the community. Look at the incidence of armed robbery and burglary in Nigeria. When have our people gone to bed and hope to wake up the following morning. What about the psychological trauma of being visited by an armed robber? What about the financial cost of erecting high walls and fences, the numerous protectors in our homes which becomes hazardous in fire out break in the homes, the guard in the gatehouse all are drain on our resources. In the UK the windows and doors are made of glass and you can be sure to sleep till morning without rude awakening from a night marauders.
You all can recall the recent killing of seven Hausa foreign exchange traders in Benin in May 2004 and the raiding of a whole street off Akpakpava Road eleven days later, and all the daily armed robbery activities our people have been made accustomed to, all in broad daylight. The robbers usually get away, if they are ever caught, it is not reported. Such dramatic events affect the psyche of the people thus contributing to ill health.
DEATH AND INJURY FROM ROAD TRAFFIC ACCIDENTS.
During the WHO celebration in April 2004, the global campaign was launched to prevent road traffic accidents, they noted that the highest number of deaths due to RTA occurred in Nigeria in the preceding year. There is more than 50% chance that one will not get to the destination when travelling on a Nigerian road. Accidents, injuries and violence are common place.
Travellers are more likely to be killed or injured in accidents or through violence than to be struck down by an exotic infectious disease. Traffic accidents and violence are significant risks in many states in Nigeria especially Edo State, where skilled medical care may not be readily available. No ambulance services, no incident support systems of any sort. A helipad was built in UBTH accident and emergency unit for quick recovery of accidents victims along the busy and accident prone Benin/Lagos Road. Thirty years on, it is still not operational. The question is not good intentions but lack of the will for implementation of our plans. The plans just die on the drawing board. Usually those awarding the contract take ten percent of the total cost, the contractors take ten percent of what is left, the sub-contractors take another ten percent and by the time the project is executed by the daily paid workers even with the use of substandard equipment, the fund is inadequate for the completion of the job hence the numerous abandoned projects that litter the landscape of our country.
It is estimated that more than 1 million people were killed in traffic accidents worldwide in 1998 and a further 10 million were injured and the majority were from many developing countries like Nigeria. In Edo State for example traffic laws are limited or are inadequately enforced. Our people are even part of the problem because they have been seen removing traffic light bulbs in broad day light unchallenged. People do not care about the traffic ordinance because if caught they will easily bribe their ways out of punishment. Often the traffic mix is more complex than that in developed countries and involves two wheel(push trucks) and four-wheeled vehicles, animal-drawn vehicles and other conveyances, plus pedestrians, all sharing the same road space. The roads may be poorly constructed, poorly maintained, road signs and lighting inadequate and driving habits are usually poor.
DEATHS FROM HIV/AIDS, MALARIA other Infections and infestations.
About 90% of all malaria deaths in the world today occur in Africa south of the Sahara. This is because the majority of infections in Africa are caused by Plasmodium falciparum, the most dangerous of the four human malaria parasites. It is also because the most effective malaria vector - the mosquito Anopheles gambiae - is the most widespread in Africa and the most difficult to control. An estimated one million people in Africa die from malaria each year and most of these are children under 5 years old
There are three principal ways in which malaria can contribute to death .in young children First, an overwhelming acute infection, which frequently presents as seizures or coma (cerebral malaria), may kill a child directly and quickly. Second, repeated malaria infections contribute to the development of severe anaemia, which substantially increases the risk of death. Third, low birth weight - frequently the consequence of malaria infection in pregnant women - is the major risk factor for death in the first month of life
In addition, repeated malaria infections make young children more susceptible to other common childhood illnesses, such as diarrhoea and respiratory infections, and thus contribute indirectly to mortality
Poor people are at increased risk both of becoming infested with malaria and of becoming infected more frequently. Child mortality rates are known to be higher in poorer households and malaria is responsible for a substantial proportion of these deaths. In a demographic surveillance system in rural areas of the United Republic of Tanzania, under-5 mortality following acute fever (much of which would be expected to be due to malaria) was 39% higher in the poorest socio-economic group than in the richest.
Nigeria now has a national HIV prevalence rate of 5.8% and a population of 3.01 million adults who are living with HIV/AIDS. The country is currently embarking on a "Care" project - to provide Anti Retro Viral (ARV) treatment for 10,000 adults and 5,000 children, at a cost of about three hundred and fifty million naira (over US$3 million). The UBTH in Benin City is one of the Centres of Excellence for the treatment of HIV/AIDS in Nigeria and their current prevalence rate is very similar to the above figure. You must note these are hospital based figures and the scale of the problem in the population will be more serious as many of deaths from HIV/AIDS go unreported.
OTHER DISEASE CONDITIONS:
Under this heading I will include diseases like hypertensive heart diseases and stroke, diabetes mellitus, other deficiency diseases like hypothyroidism, the cancers, obesity, illnesses related to stress and lifestyle which are not communicable. About 10% of the urban population have hypertension and diabetes is estimated in 2.7% of the population of Nigeria.
The above disease conditions may result mostly from having too much to eat, too much to drink, too much to smoke, too much worries associated with too much wealth, too many women and too much sex, so I shall not consider them any further especially as they account for a very small percentage of death in our population.
THE SOLUTIONS TO THE HEALTH PROBLEMS.
The most important solution is free, universal and compulsory education from the cradle to the grave. This is a policy of the present administration. Is it being implemented to the grassroots level? That is the question. Go along Uselu -Lagos Road and Ring Road in Benin City and you will see hundreds of under 16 years old, both male and female hawking pure water, bread, handkerchief, hawking any ware in search of clean money to help their parents put bread on the table when they should be in school learning. In later life, they constitute fertile ground for recruiting hoodlums who do anything for money.
It is the duty of any government to reduce unemployment figures. In Nigeria and Edo State such figures does not exist therefore reducing unemployment is out of the question. The government both state and federal is not assisting in providing the required enabling environment where economic development and private finance initiative will thrive.
If the jobless are employed or engaged in agro based industries as land is plentiful in Edo State, the crime rate will drop and more people will be energized into investing in Edo State economy. This will build in a spiralling momentum of economic development that can make Edo State the food basket of the Nation.
The security situation is worsened by the attitude of our people by no longer being there for one another. What has happened to the collective responsibility of yesteryears when our parents mounted guard (night watch or Ude)? What about when our fathers flushed out jobless but flamboyant and affluent people in our communities as suspected thieves and robbers? What has happened to the street security meetings and activities in all areas of Edo Land? The government of the day and police must lead the way in bringing safety back to Edo State. We have done this before. We can do it again. But to rely solely on the police or the paid night watchman without involvement of everybody is to fail dismally.
The prevention and care of HIV/AIDS and sexually transmitted infections (STI) should be part of reproductive health programmes at all levels including primary health care.
The management of pregnancy in HIV-positive women should be seen as part of the comprehensive and long-term care of the woman provided to her at settings within easy reach of her home.
Obstetric management will be similar to that for uninfected women (or women of unknown sero status) in most instances, although invasive diagnostic procedures should be avoided, and iron folate and other vitamin supplementation should be considered. In areas of high prevalence, these procedures should be for all pregnant women.
HIV testing in pregnancy has a number of benefits in terms of prevention and care for mother and child but this must be balanced against the possible risks of stigmatisation, discrimination and violence. In order to avoid or minimize negative consequences, testing must be voluntary and confidential and accompanied by quality counselling.
The slogan to prevent or reduce the incidence of HIV should include
Stable monogamous setting.
Improvement on the socio-economic status of the population.
There is nothing like safe sex so do not expose yourself.
The high mortality from HIV/AIDS in sub-Saharan Africa is complicated with the poor socio-economic status of the people. Poverty leads to sub-optimal innate immunity resulting from poor or inadequate nutrition or malnutrition and poor general health, which increase susceptibility to infection. Poverty makes the purchase of anti-retroviral drugs impossible and in certain situations when the drugs are available there is no portable water to assist in taking the medications. HIV/AIDS infection is therefore a death sentence in places like Nigeria and Edo State in particular whereas in Europe and America for example those diagnosed with HIV/AIDS still live active, normal lives and some of them are gainfully employed and may remain so for over twenty years after such diagnosis due to the care and social support they receive.
There is need for health promotion which in a country like Nigeria and in Edo State in particular, should be the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical mental and social wellbeing, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities.
Prerequisites for health
According to the WHO, the fundamental conditions and resources for health are social security, peace, shelter, education, food, income, sustainable resources, social justice and equity and I will add portable water. It is impossible to swallow tablets without water. Lack or inadequate water supply and poor sanitation contribute immensely to easy death and poor recovery from mild infections. Therefore improvement in health requires a secure foundation in these basic prerequisites like available and safe water supply and good sanitation.
The prerequisites and prospects for health cannot be ensured by the health sector alone. More importantly, health promotion demands coordinated action by all concerned: by governments, by health and other social and economic sectors, by non governmental and voluntary organizations, by local authorities, by industry and by the media. People in all walks of life should be involved as individuals, families and communities. Professional and social groups and health personnel have a major responsibility to mediate between differing interests in society for the pursuit of health.
Health promotion goes beyond health care. It puts health on the agenda of policy-makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health.
Health promotion policy combines diverse but complementary approaches including legislation, fiscal measures, taxation and organizational change. It is coordinated action that leads to health, income and social policies that foster greater equity. Joint action contributes to ensuring safer and healthier goods and services, healthier public services, and cleaner, more enjoyable environments.
Health promotion policy requires the identification of obstacles to the adoption of healthy public policies in non-health sectors, and ways of removing them. The aim must be to make the healthier choice the easier choice for policy-makers as well.
Strengthen community action
Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities, their ownership and control of their own endeavours and destinies.
Community development draws on existing human and material resources in the community to enhance self-help and social support, and to develop flexible systems for strengthening public participation and direction of health matters. This requires full and continuous access to information, learning opportunities for health, as well as funding support. The organisers of the sanitation crusade going on in Benin City presently should be advised against the use of poorly trained or corrupt officers as their action is causing unnecessary stress, aggravation and therefore ill-health amongst the people.
Enabling people to learn throughout life, to prepare themselves for all of its stages and to cope with chronic illness and injuries is essential. This has to be facilitated in school, home; work places and community settings like the palaces of traditional rulers and market places. Action is required through educational, professional, commercial and voluntary bodies, and within the institutions themselves.
Reorient health services
The responsibility for health promotion in health services is shared among individuals, community groups, health professionals, health service institutions and governments. They must work together towards a health care system which contributes to the pursuit of health.
The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components.
Reorienting health services also requires stronger attention to health research as well as changes in professional education and training. This must lead to a change of attitude and organization of health services, which refocuses on the total needs of the individual as a whole person.
Caring, holism and ecology are essential issues in developing strategies for health promotion. Therefore, those involved should take as a guiding principle that, in each phase of planning, implementation and evaluation of health promotion activities, women and men should become equal partners and money meant for health should be spent for healthcare and not diverted to other areas or worse still to private Swiss Banks accounts.
Commitment to health promotion
Will you pledge as you go back to Benin City to support youth clubs and organization like Boys Scouts, Girls Guide, Red Cross, Youth Sports, Community Organizations so as to take the minds of our youths away from crimes as an idle mind is the devil�s workshop.
Will you as leaders lead by examples by sharing and exhibiting live and let live attitude instead of flaunting your wealth to the annoyance of the poor and those in need. Most times our attitudes and behaviour is an invitation to armed robbery, which is avoidable.
Will you encourage moral re- armament and religious instructions in schools? This is something the State government is experimenting with by reverting the schools to the missionaries. This will help in producing children with high moral standards and reverse the current evil trend of worship of money rather than striving for honour as was prevalent and the norm in my school days.
Will you go home and give voice to the voiceless. Help the poor, support the infirmed, and help to translate our discussions into reality. Do not be complacent. Start from your family. If you make your family good, you make the community better; if the community is good, we have a better town, and if the town is good, we shall have a better State; and if the State is good, we shall have a better Nigeria which will support a better world, making our lives a lot better.
The provision of good sanitation, safe water supply, good roads, emergency team, social security for the unemployed, prevention of floods by adequate planning and execution of contracts for road building, security for life and property will all help in improving the general health of our people. This is a tall order but it is possible if our people are motivated and mobilized with those at the helm of affairs leading by example.
SEO OGBONMWAN, JULY 2004, BOSTON MASSACHUSETTS, USA.
2,The World Health Report 2002: reducing risks, promoting healthy life. Geneva,
3, World Health Organization, 2002Molineaux L. Malaria and mortality: some epidemiological considerations. Annals of Tropical Medicine and Parasitology, 1997, 91(7):811-825
4, Nigeria Reproductive Services and Manpower Survey (2001) Reproductive Health Division, Federal Ministry of Health, Abuja Nigeria.
5, Health Systems Development Project 11, Federal Ministry of Health, Abuja 1989.
6, Federal Ministry of Health, NHMIS (Preliminary Health Profile Figures) 1999.
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