By Professor Nimi Briggs
A Lead Presentation on Health By Nimi Briggs, MD. FAS. OON. At The First Biennial Conference on Human Security in Africa Held at Olusegun Obasanjo Library Abeokuta, Nigeria. March 5-6, 2009
The Continent of Africa, the world’s second largest in area and population, with a land mass of about 30.7million km2 (about one fifth of the earth’s total) and an estimated population in excess of 900 million persons, remains very insecure even with its plethora of natural resources. Many of its 54 component countries are unable to guarantee safety of lives and property for their citizens as major conflicts arising from fratricidal and internecine warfare erupt, not infrequently. Disease burden is high and so also is the scourge of hunger. Even in the area of military might, most armies are ill-equipped and their combatants, inadequately trained. Accordingly, they are unable to engage in modern military warfare. By whatever name called therefore, Human Security in Africa is tenuous.
The need to investigate and understand the underpinning factors for this insecurity becomes obvious if Africa is ever to avail its people a safe environment where they can thrive and pursue their legitimate aspirations. It is in this respect that today’s Conference on Human Security (or shall we say lack of it) in Africa asserts itself as it converges experts from diverse callings to ventilate the issue.
In my letter of invitation it was stated that The Centre for Human Security of the Olusegun Obasanjo Presidential Library, under whose auspices this conference is being held, seeks to provide a base for the theoretical, qualitative and quantitative analyses to unravel causal relationships and interdependencies which link or activate security threats in the cultural context of Africa. The Centre is of the view that the threats are multifaceted and multidimensional as human security is starting to take into account a range of evolving threats including illiteracy, poverty, food insecurity, intellectual terrorism, drug trafficking, money laundering, illegal arms dealing, institutional corruption, organized crime, disease and environmental degradation. The task before this first in the series of biennial conferences is therefore immense and I thank the organizers for inviting me to participate in what promises to be an important conference.
In normal parlance, security, be it national or continental is often hinged on the ability to defend defined territorial borders from incursion by others, considered as enemies. It is for this reason that nations keep standing armies, which are usually combat ready and also form regional defense alliances, like the North Atlantic Treaty Organization (NATO). A nation’s capacity to feed itself and accumulate surplus for commercial export or humanitarian considerations, is also, often regarded as food security, just as a sound financial base, which incorporates foreign reserves, for use in the payment for goods and services, can be looked upon as financial security; good health is not usually taken as providing any national security.
My presentation, in holding the position that the health of its people is a nation’s greatest asset, asserts that poor health is a key index of human insecurity.
My paper draws attention to the dismal health indices of most African countries and highlights some of the major diseases that contribute to poor health in Africa as well as the weak health delivery system that exists in most parts of the continent. It then examines the correlation between poor health, poverty and lack of development which are all pervasive in Africa, especially, sub-Saharan Africa. Furthermore, it points out the role of good governance in the ultimate promotion of good health and concludes with an exhortation to African leaders to place premium on the health of their citizens.
HEALTH INDICES IN AFRICA
Several indices exist which describe the state of health of a people. For the purposes of today’s presentation, only the following will be considered as they, additionally, give some indication of the standard of public health measures in an environment, which promote the health of the generality of the people: Life Expectancy at Birth; Crude Birth Rate; Crude Death Rate; Under Five Mortality; and Maternal Mortality.
Ø Life Expectancy at birth (LEB): This is the average number of years a newborn would be expected to live if health and living conditions at the time of its birth remained the same throughout its life. It indicates the health of a country’s people and the quality of care they receive when they fall ill.
With an LEB of 82.07 years, Japan is one country where people live longest in the world; the global average being 66.5 years (The World Fact book 2008). In a rank order of LEBs of 223 countries for which data were available, no African country made the global average; the bottom 56 countries were all African, except three – Nepal, Haiti and Laos; and Swaziland, with an LEB of 31.99 years, is where people live for the shortest time in the world. Nigeria, Africa’s most populous country, has a LEB of 45.5 years.
Ø Crude Birth Rate (CBR): This gives the average annual number of births during a year, per 1,000 persons in the population. It is usually the dominant factor in determining the rate of population growth and its value depends on the level of fertility and the age structure of the population.
In a rank order of 218 countries for which data was available (The CIA World Factbook 2008), Germany, with a CBR of 8.2 was where the least number of babies were born per 1,000 population. The largest number of babies was born per 1,000 population in the African country of Niger with a CBR 50.16 and the first 36 countries with the highest CBRs were all from Africa, except three – Afghanistan (46.21), Mayotte (40.35) and the Gaza strip (38.90). Nigeria’s CBR is 43 per 1,000.
Ø Crude Death Rate (CDR): The crude death rate (CDR) is the number of deaths in a year per 1,000 persons in the population.
The crude death rate for the whole world is currently about 9.6 per 1000 per year and 6 countries with the highest CDRs are all from Africa, led by Swaziland with a CDR of 30.70. Nigeria’s CDR is 14 per 1,000.
Ø Under Five Mortality Rate (U5MR): This is the number of children who die before their 5th birthday per 1,000 live births. It is a sensitive indicator of child well-being and also an expression of the quality of overall care available for children in their early formative lives which constitute their most vulnerable years.
Again as was the case in the other indices, African countries recorded the highest U5MRs in the 2008 UNDP’s State of the World’s Children Report. Sierra Leone and Niger Republic recorded U5MRs of 282 and 256 per 1000 live births respectively. With an U5MR of 197 per 1,000 live births, Nigeria is also one of the countries in the world where the chances of a child dying before its 5th birthday, are highest.
Ø Maternal Death: This indicates the death of a woman while pregnant or within 42 days of the expulsion of the fetus. The information is usually expressed as the number of such deaths per 100,000 live births.
Maternal deaths constitute another sensitive marker of the extent and quality of care that is generally available in a country especially those that respond to the peculiar needs of women and with particular reference to those of pregnant women. They are highest where development is poor and women’s health issues not treated with appropriate concern.
Many countries in Africa, Mali, Niger, Liberia, Somalia have maternal mortality rates in excess of 1,000 per 100, 000 live births. Of the estimated 530, 000 women who die each from complications of pregnancy and childbirth, an estimated 55,000 deaths (>140 per day) come from Nigeria alone. Thus although Nigeria accounts for only 2% of the world’s population, it produces 10% of the global estimates of maternal deaths. The only country that has a higher absolute number of maternal deaths is India with 136,000 maternal deaths each year. By way of comparison, maternal mortality ratios are <4, 8, 24.1, and 90 per 100,000 live births for Finland, United Kingdom, Cuba and the State of Kerala in India, respectively.
At a glance, these indices paint a dismal picture of the health profile of the citizens of many African countries. Characterized by a high CBR as well as a high CDR, they indicate a short life span on the average of people in the continent which is predicated on a high disease burden and a poor health delivery system that is unable to maintain its citizens in good physical condition and to prevent early death after birth. The indices expose a remarkable deficiency in the provision of basic health care to newborns, a good number of whom, consequentially, die before their 5th birthdays. As for pregnancy and childbearing, the indices warn that this is a dangerous process in Africa from which women stand a good chance of dying even though the process is not a disease and the interventions to make motherhood safe, are well known. The inhabitants of such a continent cannot be said to have security irrespective of the amount of armaments that are amassed for their protection from perceived enemies. The daily hazards that they face in keeping alive constitutes sufficient insecurity.
DISEASE AND POOR HEALTH IN AFRICA
Many diseases cause mortality and morbidity in Africa and contribute to the heinous health statistics that have just been considered. Due to time constrain only a few will be examined; emphasis being placed on those that affect large sections of the population, especially the most vulnerable groups. The diseases include malaria, diseases associated with intestinal hurry, vaccine preventable diseases ((VPDs), acute respiratory tract infections, as well as HIV/AIDS along with tuberculosis, which has made a recrudescence. Ill health arising from violence – armed conflicts, insurgences, and armed robberies will also receive a brief attention as they are becoming notable features of life in many African countries.
The medical literature is replete with information which indicate that malaria accounts for a disproportionate share of ill-health and deaths among many nations of the world, especially those in Africa and with particular reference to those in sub-Saharan Africa where the disease also presents major obstacles to social and economic development.
There are at least 300 million acute cases of malaria each year globally, resulting in more than a million deaths. Around 90% of these deaths occur in Africa, where a child dies every 30 seconds commonly from P. Falciparum, the most dangerous form of the infection. Malaria is Africa’s leading cause of under-five mortality (20%) and constitutes 10% of the continent’s overall disease burden. It accounts for 40% of public health expenditure which amounts to about US$ 12 Billion every year, 30-50% of inpatient admissions, and up to 50% of outpatient visits in areas with high malaria transmission. Malaria and poverty interact in a vicious circle and recent evidence suggests that there may be a link between malaria and HIV: malaria infection during pregnancy may increase the risk of mother-to-child transmission of HIV. Indeed, in many ways, Africa’s future development is inextricably linked to the success of malaria and HIV/AIDS prevention and control.
The disease remains a major public health challenge in Africa, with high and escalating infection rates which have been worsened by the deteriorating environment which enhances vector propagation and the appearance of strains of the infection which are resistant to cheap chloroquin and thus require more expensive artemisinine containing compounds for their control.
Diseases Associated with Intestinal Hurry.
Diaorrheal disease is common in children in Africa especially those under three years of age mainly because of poor sanitary conditions and unsafe water for drinking and for domestic use. Oral Rehydration Therapy (ORT) which replaces the fluid and electrolytes that are lost through frequent stooling and vomiting has ameliorated the mortality and morbidity associated with the disease to some extent. But the infection remains one of leading causes of under five mortalities in several African countries.
Outbreak of severe diaorrheal disease, such as Cholera, also occurs in adult populations in Africa and inflicts a heavy toll in mortality and morbidity on the community, stretching already impoverished medical facilities to their limits. The recent episode of Cholera in Zimbabwe, at the peak of the political crisis in that country (December 2008), is reported to have affected about 60, 000 persons of whom, about 3,000 died.
Vaccine-Preventable Diseases (VPDs)
Several childhood diseases are preventable by vaccines. They include poliomyelitis, tuberculosis, diphtheria, whooping cough, measles and tetanus. Infant immunization has thus become an effective public health intervention to reduce the morbidity and mortality of vaccine-preventable diseases. Whereas developed countries have used this measure to great effect and have succeeded in drastically reducing childhood deaths and ill-health from the VPDs, some developing countries, especially those in sub-Saharan Africa fail to achieve desirable vaccination coverage for several reasons – cultural taboos, epileptic electricity for vaccine preservation, inadequate campaign strategy, to mention just a few. Not even the launching of the Expanded Programme on Immunization (EPI) by the WHO in 1974 which was meant, among others, to enhance the chances of meeting the universal child immunization (UCI) target of immunizing 80% of the world’s children by 1990, changed the situation in any appreciable manner. Accordingly, these diseases remain major causes of death and disability in many African countries. Poliomyelitis which has been virtually eliminated in other parts of the world is still a scourge in Nigeria, Africa’s most populous country. It was this unfortunate situation that prompted the recent visit to the country (February 2009) by Bill Gates of the Bill and Melinda Gates Foundation (a philanthropic organization with major interest in helping the poor and with strong global reach) to boost support for the eradication of the infection.
Acute Respiratory Infections
Acute Respiratory Tract infection is another common disease which kills a number of children in Africa. The infection could be either in the upper or lower respiratory tract. Upper respiratory tract infections are the commonest infectious diseases and include rhinitis (common cold), sinusitis, ear infections, pharyngitis and tonsillitis. The common lower respiratory tract infections are bronchiolitis and pneumonia; the two can be caused by bacteria and viruses. The prevalence of lower respiratory tract infection varies with age. It is relatively low in the first six months of life, peaks in the second year and falls in the third.
HIV/AIDS and Tuberculosis
First discovered as a new disease among young homosexual men in New York and Los Angeles, in the United States of America on December 1, 1981, it was soon confirmed that HIV/AIDS is caused by a retrovirus which attacks the natural immune system of the body, thereby making it possible for many different infectious diseases, including those called opportunistic infections that are usually only able to strike when the body’s defenses are weakened, to take hold of the affected.
The infection is now pandemic in humans. As of January 2006, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the WHO estimate that AIDS has killed more than 25 million people, making it one of the most destructive pandemics in recorded history. In 2005 alone, AIDS claimed an estimated 2.4-3.3 million lives of which more than 570,000 were children and it is estimated that 40 million of the world’s population currently live with the virus.
Over time however, the disease has become essentially an African, and in particular, a sub-Saharan African problem where more than a third of those dying from the disease occurs, retarding economic growth and deepening poverty. Africa with just over 10% of the world’s population carries well over 75% of the burden of the disease and in 2005 lost 2.4 million adults and children to AIDS.
Southern Africa is home to 15 million people living with AIDS or 40% of the world wide total of 40 million people living with the virus. In Zimbabwe, at least 3,000 people die each week from AIDS related illnesses in the country of some 12 million people and last year, South Africa, where 1,500 new infections and about 900 deaths occur each day, mounted a new and more vigorous 5-year response against the infection under the direct supervision of the country’s Vice President.
As for tuberculosis, a WHO report, released on the 22nd of March 2007, indicated that a global decline in the disease is being hampered by HIV/AIDS and the emergence of extensively drug-resistant strains of the infection.
Again, Africa accounts for more than a quarter of all the TB cases in the world and the epidemic continues to increase in Africa despite the implementation of effective TB control strategies. Approximately 35% of all TB patients in Africa are HIV-positive and in 2003, an estimated 80% of the people co-infected with TB and HIV who died, were in Africa. HIV is the main reason for failure to meet TB control targets, particularly in sub-Saharan Africa. This synergy between the two infections constitutes a major challenge in the efforts that are aimed at their control.
Nigeria, Africa’s most populous country, is one of the 22 nations of the world with the highest burden of the disease where it ranks 4th and 1st in Africa. The incidence in the country is reported as 293 cases per 100,000 per year and 25-45% patients with HIV presenting for ART access have TB.
Violence and Ill-Health.
In the report it launched in October 2002, on Violence and Health, WHO stated that each year, more than a million lives are lost and many more suffer non-fatal injuries, as a result of various forms of violence and that overall, violence is among the leading causes of death worldwide among people aged 15-44 years.
All would agree that over the years, Africa has had more than its share of armed conflicts, armed crimes and other forms of violence for which colossal losses have been incurred by way of deaths and disabilities of individuals, destruction of infrastructure and lost opportunities for development. The struggle to dethrone the apartheid regime in South Africa was vicious and claimed several lives on both sides of the ideological divide. Angola, Liberia, Sierra Leone, Democratic Republic of Congo, Somalia, and Eritrea are all flash points where extensive wars have left in their wake, massive destruction and loss of lives. Nigeria fought a civil war in the late 60s and even now is not at rest because of an upsurge in violent crimes especially in its Niger Delta region.
In economic terms, the losses have also been staggering. In 2007, IANSA, Oxfam, and Safeworld (all philanthropic organizations) estimated the economic cost of armed conflict to Africa’s development since 1990 as being $30bn (Africa’s Missing Billions). The organizations stated that this amount has been lost by Algeria, Angola, Burundi, Central African Republic, Chad, Democratic Republic of Congo (DRC), Republic of Congo, Côte d’Ivoire, Djibouti, Eritrea, Ethiopia, Ghana, Guinea, Guinea-Bissau, Liberia, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, South Africa, Sudan and Uganda. The amount was equivalent to what the continent had received in aid.
There are also the health implications of violence to contend with. Studies emanating from the University of Port Harcourt have shown that aside from the physical disability which those who survive violent crimes and warfare sustain, Psychiatric disorders are rife and manifest commonly as Post Traumatic Stress Disorders as well as other anxiety conditions, hard drug related ailments, schizophrenia, psychosis, depression and other forms of affective disorders.
A close examination of the conditions that give rise to the dismal state of health of Africans shows that they are mainly communicable diseases of infective origin. Such diseases are usually preventable and are commonly associated with poverty which has entrapped a people in poorly developed environments with inadequate sanitation, scare clean pipe-borne water and paucity of communication networks, including roads. These factors, along with inherent difficulties in the health system which is weak and not sufficiently responsive to the demands of acutely ill patients, ensure that the diseases take a firm hold on the community and thrive. Let us now examine the health delivery system in Africa.
HEALTH CARE DELIVERY AND POOR HEALTH IN AFRICA
Since most countries in Africa suffered colonization from Europeans, it is not surprising that the structural formation of the medical services of most African Countries is a throwback to those of their colonial masters. The colonial masters were, in the main, British and French, and so health services on the continent tend to be developed mostly along those two lines.
Using Nigeria as an example, the country’s health delivery plan took its origin from the colonial Armed Forces Medical Corps in the 1940s. It was subsequently modified in various Development Plans until the early 1980s when, under the late Olikoye Ransome Kuti as Minister of Health, a comprehensive health delivery system was articulated. This consists of a preventive and promotive Primary Health Care at the Local Government Level, a curative Secondary Health Care at the State level, and a rehabilitative Tertiary Health Care at the Federal Level, which also has a major responsibility for medical education. The system is meant to be comprehensive, integrated and of universal coverage, with a robust referral system between the various levels of care. The hospitals, clinics and other health institutions through which care is delivered at the various levels are all owned by government.
Aside from this, health care is also delivered through private health institutions and traditional health practitioners. On account of the multiplicity of problems facing public health institutions in Nigeria, most persons utilize others sources of care and visit public health institutions as a last resort.
This pattern is replicated in most African countries especially those that were colonized by Britain. Furthermore, the use of traditional health practitioners side by side of orthodox medicine is universal in Africa.
POVERTY, LACK OF DEVELOPMENT AND POOR HEALTH IN AFRICA
Despite an impressive array of natural resources, poverty remains central in the lives of many Africans. Africa is the only continent that got poorer in the last 25 years and more than one half of the world’s poor (those living on > 2 dollars per day) is found in the continent. In 2006, 34 of the 50 nations on the UN list of the poorest countries were in Africa and In many African nations, the GDP per capita income is less than $200 U.S. per year, with the vast majority of the population living on much less than one dollar per day.
To alleviate poverty and to bring about development, several African countries have mounted specific development programmes. In Nigeria, the present administration of Umaru Musa Yar’Adua which was elected into office in May, 2007 has instituted a Seven Point Developmental Agenda plus Two Special Issues which are aimed at transforming the country into one of the world’s 20 largest economies by the year 2020:
· Power and Energy;
· Food Security and Agriculture;
· Wealth Creation and Employment;
· Mass Transportation;
· Land Reform; Security;
· Qualitative and Functional Education;
o Plus Two Special Interest Issues…
§ Niger Delta and
§ Disadvantaged Groups.
Even with all this, Nigeria currently remains an underdeveloped and poor country which had frittered away several opportunities to have bettered the lot of its citizens. According to UNDP publications of Human Development Indices (HDI – Human Development Index – a measure of the quality of life and well-being of a people, with 1(one) as the highest possible HDI) which was updated for 2008, Nigeria occupies the 155th position out of 180 countries. Similarly, most African countries were crowded at the bottom where they were classified as countries with low HDIs.
It is this state of poverty and underdevelopment with “infrastructural deficit” that is blindingly obvious, that so badly affects social services in Africa. For, it ensures that priority attention is not given to the health delivery system; that the system is poorly funded, inadequately staffed and functions inefficiently. It is responsible for the large number of illiterate and ignorant persons in the continent who are unable to take some responsibility for their own health and so do not even utilize the existing health services, such as there are. It explains the large number of poor persons (those who live on < two US dollars per day) in the continent that is unable to pay for medical care. It assures the absence of essential drugs in health institutions and also the absence of cheap and reliable means of transportation with which sick persons can be quickly transferred to better equipped centres for expert care when life-threatening complications arise in the course of an ill health. It adds on to the tremendous delay that is experienced in many health institutions in Africa which contributes significantly to deaths even in major hospitals. Furthermore in several African countries, electric power supply is epileptic and there is a dearth of clean water even for use in health institutions. Live saving emergency operations get postponed for several hours on account of this.
Health Delivery Systems do not exist in isolation. They function best as part of a holistic package of social responsibilities involving intersectoral collaboration. This ensures that in addition to the health facilities, there are good roads, potable water, clean environment, steady electricity supply and also good educational institutions where, among others, the tenets of personal hygiene are taught.
This type of intersectoral collaboration which supports health delivery systems hardly exists in many African countries.
When Ghana successfully negotiated and obtained Independence from its British Colonial rulers as the first African country to do so in 1957, it declared that its independence was meaningless unless the process was extended to the other countries in the continent, which were still under servitude. It sloganised, through its visionary leader, the late Osajefor, Dr. Kwame Nkrumah, that “Africa must be free; total liberation for this continent now”.
The understanding was that political independence, which was to bequeath to Africans, complete responsibility for their own affairs, would usher in rapid economic and infrastructural growth, an egalitarian society and a vastly improved quality of life for the citizens of the continent. The unparalleled availability of natural resources in the continent as well as what appeared then to be an unquenchable craving in African leaders to achieve this goal, gave credence to that position.
It is now about a period of half a century from the late 1950s when decolonization in Africa commenced. But sadly, with all African countries now decolonized, it cannot still be said that life has meaningfully changed for the better for most Africans. Outside a few success stories, wars in which citizens of the same nation mercilessly kill and maim one another have become commonplace in a number of countries just as their leaders and nationals along with their foreign collaborators, plunder the national treasuries remorselessly. Infrastructural development – all-seasoned road connections, rail transportation, piped water for domestic use, electricity to provide energy for development and national growth, and educational facilities had been diminutive and in many respects, fallen short of national ability. As an escape from this morass, and in attempt to seek a better future elsewhere, many Africans, especially the youths from sub-Saharan Africa, flee the continent in droves, even through illegal and extremely hazardous means.
Specifically, in the health sector, most of the health delivery systems that are provided by Governments in the continent are dysfunctional and not operating as efficiently as they should. They are often poorly funded, inadequately equipped and badly managed and so are usually unable to satisfactorily meet the health needs of the generality of the people of the continent. Those that can afford it, seek care outside, those that cannot, grapple with the inefficient system.
Most persons have ascribed this backwardness of the continent to a leadership crisis (corrupt, hollow, inept and self-seeking) which over the years had been the fate of some countries in the continent. To correct this and to make governments in Africa to be more accountable to their people, African leaders formed the New Partnership for Africa’s Development (NEPAD) as the development arm of the Union. Outside issues of Pan Africanism, formation of a United States of Africa and more recently, the African Union Authority, NEPAD aims to provide an overarching vision and policy framework for accelerating economic co-operation and integration among African countries and also a peer review system to ensure transparency and accountability in governance in Africa.
Unfortunately things still do not appear to be moving rapidly in the right direction. Not even the M O Ibrahim Foundation for good governance in Africa through five well-defined general criteria appears to be changing the course of governance quickly for the better. Recent disputed elections in Kenya and Zimbabwe resulted in the death of several persons even as the war in the Democratic Republic of Congo rages on and Somalia can now pass for a failed state.
The current global financial meltdown and collapse of established economies will most likely hit Africa which is probably the most vulnerable continent, hard, and so, may even result in a further deterioration in the quality of life and standard of living of its people. That much was said at the recent meeting of Heads of Government and major players in the global financial system in Davos, Switzerland.
But Africa should see in this catastrophe, as another opportunity to redirect its affairs. The natural resources that have served as a curse (the struggle for their control has been the most important cause of conflicts in Africa) and blessing (some of them have supported national economies singlehandedly) may dwindle further (crude oil now sells at <$35 per barrel, down from >$160 in September 2008). Global economies are from henceforth more likely to be supported by Science, Innovation and Technology into which Africa must key if it is not to be left behind once again. A health system that is accessible, affordable, functional, and responsive, should not be beyond the ability of African leaders to provide for their people; it can only exist in an environment in which other social responsibilities to the people are also met.
It is when such an environment exits for Africans in which they can afford the basic necessities of life and their individual and collective health needs sufficiently catered for within their own borders, that their LEB would sufficiently rise to a level to make them become worthy of being protected by standing armies. In Africa, poor health is therefore an important index of insecurity.
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The 13th Abimbola Awoliyi Guest Lecture
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Nimi Briggs 2007 Change in Lifestyle as antidote to emerging diseases
The 13th Abimbola Awoliy Guest Lecture delivered at the 2007 Biennial Conference of the Medical Women Association of Nigeria.
Nimi D. Briggs,
University of Port Harcourt., Nigeria