There are so many promises – Health for all, Food for all, Water for all, Education for all, House for all, National Health Insurance, Economic Empowerment and Strategy Development, Eradication of Poverty et cetera. It does not mean much anymore, does it? The unpopular question is whether Nigeria can afford ALL. None of these is impossible if done with practical planning, reasonable statistics or estimate, in stages and by priority. Dedicated planners have tried and failed for reasons that went beyond their control.
The World Health Organization and the Federal Ministry of Health came up with Health For All by the year 2000, by Primary Health Care in the early 1980s in Nigeria. Health was defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. They wanted a level that would lead to socially and economically productive lives. So it was not just health, it was health for a purpose, that would raise standard of living of the poor.
If anyone wants to see hard working people, Nigeria is one of the places to look at. Raising standard of living in Nigeria should definitely apply to the hardest working people in the whole world. They work from dawn to dusk and hardly get any respect or a little pay for their sweat. They are the farmers, hunters, fishermen, hawkers, waste disposers and helpers in different homes. They hardly ask Nigeria for anything because they have given up. The meager earnings come from their sweat. Indeed, they believe Government is there for the big men not little people like them. If anything, Government takes from them in form of trading taxes on the spot. During elections, if there is any, they might be bribed with a bag of subsidized imported rice that would discourage production of their indigenous rice.
Health for all has been called names like social medicine, social justice or environmental justice but hidden in all these is how to spend the health money. Different countries have adopted a variety of programs to deal with their health situations. Some have established programs for the weakest members of their society or the working poor or the elderly. The amount of health care a country can afford is being debated in every country including Nigeria. In the end, the health need of the poor is cheaper and therefore cover more people compared to the exotic diseases of the very few.
If we go by what is already known, a Country like Nigeria would spend its health money on Primary Health Care and less on tertiary care. By that statement, I have already stepped on toes. Nigeria is a Country that talked primary care but spent on tertiary care. It could be a different situation if private companies establish private hospitals as we have in our State capitals while the Government supports them with left over money from primary care by strategic locations, sharing of diagnostic equipments and elective surgeries, like magnet teaching hospitals. As it is, Government hospitals are referral post for private hospitals. In cases where it is seen fit, patients are flown outside the Countries. I must hasten to say that it is not that simple. Whoever is sick, anywhere, wants the best healthcare his/her money can buy! Only a dying man knows the pinch of death.
This is loaded. We are making a choice here of where to spend health money and for whom. We can all agree that all the big hospitals in Nigeria can not function because of lack of equipment and maintenance. Even though, Nigerian doctors are some of the best in the world. Only so much out of our budget is allocated to health, most of which pays salary. Why build what we can not maintain for few people and neglect clinics we can use for many people? This question is answered differently as some examples will demonstrate how complicated it gets.
Britain used to have a liberal policy on health care for everyone regardless of how low the income. Some Nigerians also took advantage of this generosity. When Edward Heath became the Prime Minister, the Conservative started chipping away from what they considered free for all health care. Today, with a Labor Prime Minister, the tightening up has not been relaxed, so health care in Britain is not as generous to the users and foreigners have to pay a stiff price. While Sweden, Switzerland and Holland are still generous, changes have been made over the years that chipped away at the benefit. Recently, Germany Social Democrats lost an election in one of the largest Region to more conservation Christian Democrats, so the swing to the right in healthcare continues in Europe as more conservative governments win elections. This may lead to the rejection of European Union as some of the countries may want to retain their health and social fabric without interference from a central body or immigration.
These differences in approach between conservatives and liberals are more pronounced in America between United States and Canada. Canada has what is called, a single payer system. The tax is collected by the Government and everyone gets healthcare without paying directly. United States considers this socialist medicine and will not adopt this in any way. While everyone in Canada can see a doctor, go to hospital for treatment or an operation, you have to be insured in United States to get these services. It must be noted that United States has Government Insurance that barely cover both the poor and the elderly. Another experimental insurance now helps working poor to buy insurance at their place of work since they can not afford it.
There are reasonable justification for each of these two policies in Europe and America. It is briefly mentioned to appreciate how complicated decision of health planners and Governments are. If you open the health system without restrictions, more people will use it more often because money does not come directly from their pocket. The more money that people pay directly from their pocket, the less healthcare they use. As the cost of health care increases, insurance companies demand more money at the time of service and insurance premium increases. In US, unlike Canada, private companies with certain number of employees offer health insurance. Policy makers want to encourage more companies to offer health insurance. The Government should not do what private companies can do, United States health policy makers would argue.
However, people who can not afford healthcare postpone their ailment until it becomes grave before they see a doctor. In many cases, these ailments could have been prevented if there is access to healthcare. That is, prevention is better than cure. So in the United States, those without health insurance, Medicare or Medicaid may not have access to healthcare. Some use emergency services in the hospitals at certain point though. Since all the emergency departments can not take in all these patients, some of the hospitals have closed theirs.
They also point to weakness in the Canadian health system because of waiting period for elective surgery and diagnostic equipment. As a Canadian that has the money may cross the border for these services if he can not wait, so does an American who finds healthcare cheaper in Canada. For example, to deliver baby in Canada or buy prescription drugs.
Cuba has a very good health care system; they can even afford to send doctors to other countries. Their salary is not that different from others in Cuba as in Russia. But I learnt my lesson in the seventies when a teacher I had thought was an armchair professor told me Nigeria and Kenya will never be socialist countries. There are certainly more than the scenario I have given but this is enough to make my point about what we need to take into consideration to fit our way of life in many developing countries like Nigeria.
Traditional Medicine: Africans know how to care for one another. We do not send our relatives to some home to be cared for, except hospitals. That caring in us, must be cherished. There is a purpose for every one of us in life, so we must never loose sight of our usefulness no matter how small or mighty we may be. We cry so much about Nigeria, we forget to count our blessings.
Africans have been looking after their sick and also took care of their poor before the advent of the missionaries. People came from outside and rediscovered our aspirin, antibiotics, antifungal, different types of drinks that cleanse the body (agbo). We have limited these as a profession that is passed from certain parents to children. Even in the worst of times, we had silver linings. During the dark period of Nigeria-Biafra war, we improvised, so many discoveries were made to sustain the sick, body and soul. As soon as the war passed, we lost most of them.
The reason some of the traditional medicine are unattractive is the lack of transparency, unsanitary and sometimes poisonous portion/medication associated with it. Some method of traditional medicine is shrouded in secrecy because recommended palliative is worse than the problem. We now have human parts dealers searching and selling all over the world acting as middlemen for medicine men that makes unholy demands. Go to some of those Ethnic markets around the world, there are locations where banned animal parts are sold as aphrodisiac or “donated organs” for transplant arranged.
While others around the world have investigated and improved on their witchcraft, magic and applied science to sort fake, deceit from medicine, we cry in amazement when our shrines are exposed. We pretend as if it only happens in certain part of Nigeria or only in certain part of the world. A few traditional kings have been chased out of their domain and blame for every calamity for not performing ungodly rituals before ascending their throne. Meantime, AIDS, malaria and sickle cell diseases are still ravaging our population in spite of cures that has not been fruitfully developed.
This hypocrisy can be understood if we examine the justification for healthcare to preserve dear life compared to the taking of life. The whole world have used religion, communism, democracy, capital punishment, slavery, self defense, war, even sex, et cetera to justify the reason for taking life. We brag about how many times over, we can destroy the world and the use of preemptive strikes. But for the men and women of reason who do not succeed all the time, a few humans all over the world can destroy long established peaceful co existence by disguising killing as sacrifice. We must preserve life through healthcare not sacrifice life before the altar of our selfish ends. We have to work continuously on our opportunistic primitive instinct. We have to establish civilize and reasonable ways to control our population.
Primary Health Care in the 1980s: Implementation of Health For All By The Year 2000. There is no way to discuss Primary Health Care in Nigeria without the world greatest community health worker, Professor Olikoye Ransome Kuti. He had started the work in Nigeria with International grants and was determined to take healthcare to the hardest working Nigerians in their towns and villages. By the time the Federal Ministry of Health took over Primary Care, many people expressed doubts as the Professor returned to University of Lagos Teaching Hospital. Nevertheless, he remained committed to the goals as the guiding light. The irony was, he later became the Minister of Health.
Nigeria had 19 States in this time period. 20 health clinics, 5 primary health centers and one comprehensive health centers were built in each State. The plan was flexible enough to accommodate the existing clinics or hospitals or priority of each State. Health Officers (physician assistants), nurses and health aides were trained in the schools of Health Technology and posted to the rural areas to staff the centers. Health Officers and Aides were local enough to prevent brain drain. All the mono trained health aids (leprosy or tuberculosis aides) were multi trained. It did not take much more to train them about simple combination of salt and water for oral re hydration in the case of diarrhea, or keep surroundings clear of stagnant water, or boiling of well water. Conferences, workshops and trainings were organized on regular basis to bridge knowledge between Teaching Hospitals and the staff of the centers.
In spite of reduced allocation from the Federal Ministry of Health, International organization worked in unison with the staff of Primary Health Care Implementation Agency. WHO, UNICEF, UNFPA supplied logistics for training, vehicles for transportation of staff into towns and villages, provided grants for hotel accommodation in the capitals cities. In between workshops and conferences, staff would leave the hotels at dawn to be driven to rural areas for training, to monitor field health officers, nurses, aides, inspect buildings and supply equipments. By the time Primary Health Staff were driven back to their hotels, it would be dusk. Nevertheless, reports and minutes of the day had to be written for presentation the following day and accountability to funding agencies. It was a demanding but fulfilling job. Who could have predicted that a Nigerian military Dictator would cause international isolation of the whole Country?
There was this village, like many, where traditional medicine man was so popular, more people were patronizing him than the health centers. Fortunately, he had grown children. Those children were recruited as health officer, nurse and health aides. Before they graduated, traffic increased at the health centers. Some of the traditional medicine men who agreed to take some training were awarded certificate to display. This way, Primary Health Care was able to monitor them, expanded and gained the trust of the communities.
Professor Adeoye Lambo, who was the head of World Health Organization at one point, included traditional medicine in his practice at Aro Hospital in those days. The fact that traditional medicine is not fully integrated in Nigeria only shows that more advocates are needed. Nigerian videos are now demystifying ritual practices long considered sacred. Many people are appalled by the fetish practice on these videos. The good part is that people now understand and see what was hidden and so can be investigated and sanitized.
We have to look at our priorities in terms of food, water, shelter - our basic needs; without health everything else is useless. It seems like a long time ago now, when India and China populations were starving while Nigerians had enough to eat and drink. Both Countries were able to solve their hunger problem and mobilized their bare foot doctors to provide adequate health care for their populations.
It has been identified that our health problem, like most developing countries, weighs heavily on the infectious and the parasitic diseases. Some would argue that the greatest achievement that solved this problem in Europe was not medicine, but engineering control of sanitary sewage and polluted water. Nobody would deny the role of Epidemiology though.
Expanded Program on Immunization ran into trouble in Kano about a year ago because of suspicion of hidden birth control agenda. During this period of suspended polio vaccine, some children came down with a virus that could have been prevented. Finally, it was resolved between the politicians, traditional rulers and health policy makers. They must be commended for their effort and this working cooperation should be extended to other programs and areas. Population control has never been an easy sell among conservatives all over the world.
While growing up in Nigeria, one of the politician’s solutions to population growth was that Nature would take care of it by natural disaster. Some years later, at Sick Children Hospital, one of the physicians was making arrangements to lead a team to Africa. One of his colleagues asked him who was going to feed all the children after they have been saved. Being young and idealistic, I was furious at this question which I thought was callous. Luckily my skin color could not betray my changed face. I later found out that the same physician was part of the team traveling. A few years ago, in environmental health, I was confronted by an angry lady, sharing the views of many, demanded my presence from one of our senior environmental investigators. She wanted to know why she had to spend money to remove lead paint from her house. If lead poisoning was more important than food and shelter, the same money needed in order to provide for her children.
The point here is the choice between food, water, shelter and healthcare is not easy but Primary Health Care success can help sort it out and solve population explosion. Indeed, population control is part of primary health care as family planning. We heard so many stories about China and their method of forced family planning. If we do not institute family planning and there is population explosion gravitating toward our major cities as in Nigeria, we might overrun our facilities and our food supply (haven’t we?). At this point food is the primary concern of the family and not healthcare. There should not be competition between food and health. The reasons for this are the diseases caused by lack of proper nutrition and the diseases caused by lack of adequate supply of clean drinking water. In countries with abundant supply of food and clean water, selecting what to eat is the problem. But in other countries, getting what to eat and access to safe water are the problem. Nigeria sits by Atlantic Ocean! In any case, health education and information have to come from primary health care.
Kwashiorkor and malnutrition in the form of eating the same thing without varieties is common, if there is something to eat. My experience is that in spite of variety of food, there is that tendency to eat the same thing all the time. Why eat only corn meal, or just gari, or only hamburger or just fish and chips day and night when food in different combinations, shapes, colors and makes in small portions will do? My favorite dish was plantain (dodo) rice and beans. We had a military Governor in those days who said, he only ate pounded yam three times a day! Vegetables grow in abundance in tropical countries but imported food sometimes replaces the taste of varieties.
There are different types of sugar drinks these days that people, especially children forget about plain water. It gets worse with lack of clean portable water. Diseases of stagnant dirty water are endemic. Guinea worm (dracunculiasis) or malaria by mosquito larva from stagnant water. Snail fever (schitosomiasis) while swimming or bathing in dirty water, elephantiasis (lymphatic filiariasis) causing massive swelling of the leg or scrotum. River blindness (onchocerciasis) worms damage eyes. These and many others sound sick without catching it.
We can prolong life in a growing population: Living a long productive life is better than having a short life that can not care and provide for those we leave hind. A productive life includes the ability to control ourselves in synch with our environment. Therefore a predictable long life is a product of healthy environment and a short life is a product of sick and polluted environment.
In a well controlled environment with reliable statistics, we are noticing a decrease in population growth. Some families are having less or no children. It has got to a stage where Governments are paying families to have children. It happens in Quebec, Canada. Children also get baby bonus in Canada. In United States, the tax system rewards those with children up to a point. Some of these countries in Europe and America now have older population without enough younger population to support their social security. The rich have money, the poor have many children.
The result of adequate planning for both economic and social well being is the ability to cater for controlled population. Health For All means physical and mental peace in a planned environment by a controlled population. As the population aged gracefully, they determine the number of their support and replacement.