Africa’s health: Matters arising

Continued from yesterday

An example — the Onchocerciasis Control Programme (OCP) In 1952 the curse of River Blindness was exposed by a great pioneer, the blind Sir John Wilson. He described his visit as a younger man to northern Gold Coast (Ghana) in 1952. “Fifty people met us on the muddy bank of the swollen river. They were like specimens from a medical museum and behind them their village lay silent as a cemetery.

As we left those villages. I felt sick and angry and was possessed with the urgent need to get something done about the situation.” That righteous anger is needed by those of us concerned with health today if we are going to pursue policies which benefit the voiceless, the forgotten, the ill-served and the poor. The voiceless disabled poor of West Africa who had River Blindness have been wonderfully helped by the OCP in which WHO, the Word Bank, UNDP and FAO worked together and with 12 countries. The infecting parasite, Onchocerca volvulus, is transmitted by the bite of the Black Fly, appropriately named Simulium damnosum, and so the programme began in 1974 with spraying from’ helicopters of the fly’s habitats along streams. In 1987, big pharma represented by Merck & Co., Inc., decided to give their drug Mectizan (Ivermectin) to strengthen the programme.

OCP was closed in December 2002 after it had virtually stopped the transmission of the drsease in all the Participating Countries except Sierra Leone, where operations were interrupted by a decade-long civil war. The curse of conflict against health, yet again. 30 million people in 11 countries protected from the debilitating effects of river blindness, 600 000 cases of blindness prevented, 18 million children born in now- areas spared from the risk of River Blindness. For those poor farmers, th~e is hope. They need no longer fear for their children’s sight or dread their own inability to farm and provide for their families: 25” million hectares of land are now safe for cultivation and resettlement.

1 oCP shows that an imaginative partnership can promote health and economic development among forgotten people in far places. Its work has been continued in APOC, the African Programme of Onchocerciasis Control with resplendent effects.

The Partnership Model

These international partnerships use many millions of dollars and are a loud voice in, global health. Smaller partnerships in which research foundations, professional organisations, medical schools and hospitals work together are just as important for local development and training. I was reminded last month by a Nigerian born colleague that her professional Diaspora Association is very keen to promote lasting, effective partnerships.

In October 2016 the Wellcome Trust shifted the centre of gravity of its funding for African science from the UK to Africa. It handed two major research programmes, which have a strong focus on training and supporting the next generation of African researchers and research leaders, to the African Academy of Sciences’ Alliance for Accelerating Excellence in Science in Africa (AAS-AESA). Dr Jeremy Farrar, Director of the Wellcome Trust, said that lithe biggest improvements in health will be met through research that is Africa-led and locally relevant. We’re delighted that the African Academy will now take the lead in shaping a world- class research agenda driven by the next generation of African research leaders”.

The World Bank’s ambitious Western and Central Africa Higher Education Centres of Excellence programme will also be successful if there is firm leadership, accountability and enough progress to win additional funding outside the Bank. The Carnegie Corporation gave Ghana significant support to train obstetricians, and the Rockefeller Foundation supported the development of Clinical Epidemiology in selected centres.

Professional Colleges are working together, whether the West African College of Physicians and the Royal College of Physicians of London for medical education, or the College of Surgeons of East, Central and Southern Africa (COSECSA) and the Association of Surgeons of Great Britain and Ireland (ASGBI).

This was initially funded through THET (the Tropical Health and Education Trust – www.thet.org} an organisation which some friends and I founded almost thirty years ago. Our abiding philosophy has been to respond and not to prescribe. We have been~able to raise funding, often small, designed to meet the training needs of Ministries of Health and of Medical, Nursing and Schools for other disciplines. Our Government has given us generous support throughout our years; we specialise in promoting partnerships which are mutually beneficial, and which serve the poor.

King’s College Hospital in London has helped Somaliland, devastated by its wasteful and bitter civil war, to rebuild its health services and to support two medical schools. Conflict throttled but did not asphyxiate health and development.

Amoud University in Somali/and was determined to make its education relevant. Visitors from King’s and THET worked alongside the students to help the nomadic community and to learn, for example, how many hours women hod to spend fetching and carrying water and how children’s growth was monitored. Only when such manifestly privileged students have been confronted by the lives of the poor will they be even remotely prepared for senior posts later in their Ministry of Health, and responsible for health care for the nomads. This principle is not limited to Somaliland and nomads, it should be applied all over Africa.

Rural work for medical students

In Zaria I regularly took students to see how a patient, whom they had followed in hospital, lived at home. A small thing, perhaps, and we did not evaluate our visits, yet the comment of one of our students from Lagos showed that he was learning about his country – “Prof, I did not know that all these people lived here”. Was he showing that medical education can be a vehicle for understanding and of mutual trust?

In llorin, our Vice – Chancellor encouraged us to be radical. We lived with students in villages and worked with them in a poor area of llorin. so that together we could learn how rural or urban poor people lived. One morning in Borgu, between 0530 and 0600, we went with a farmer who was to plant yams and measured his heart rate and rate of breathing over two hours.

Simple exercise physiology in the laboratory of the farm! We called this work COBES, Community based experience and service, a term also now used by Moi University in Eldoret, Kenya where COBES is mandatory for medical students.

Such rural work was possible when there was only a small number of students but, when numbers rise, even when many of the academic staff work with students in the community, it is logistically and financially much more difficult. Yet, if health services are to respond to need rather than follow an outdated model; if health services are to be managed by those who have experienced how disease can defeat a deprived family; and if health services recruit those who are determined to help the disadvantaged because they have worked for them as students, it is imperative that those of us who have responsibilities in medical education wake up, rethink and re-plan how our medical schools relate to their country’s current and future needs.

I used to discuss, as old friends do, with the late Professor Olukoye Ransome-Kuti, before he became Minister of Health, how we could achieve this because big hospitals emphasise, understandably enough, a limited biomedical focus. They promote excellence in individual health care, which is fundamental, but to day’s vision for health has to be wider.

I have described rural work forty years ago. There is still much to be done for those in villages, but the urban poor are voraciously in need now. The opportunities are massive. It thoughtless and cruel for the privileged to forget the poor and, with rural and urban poverty growing, it is irresponsible and dangerous.

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Urban migrants

Forty years ago the river of urban migrants had not yet become a torrent and that torrent, in some great cities, had not yet burst its banks and become a flood. While preparing this lecture I found a short paper, Africa’s future is urban, from 001, the Overseas Development Institute, a London-based think tank. It is available online and has valuable references.

Sub- Saharan Africa has nine mega cities of 10m or more already. The urban population in Europe grew from 15 per cent to 40 per cent in 110 years; Africa has done that in 60 years. Now the most rapid growth is in its cities of between 50 thousand and one million people, where urban growth is informal, piecemeal and unplanned. Entrepreneurs flourish of course, but local authorities struggle to provide basic services and thus decent living conditions, clean water and an environment to ensure good public health, with adequate schooling and public games and recreation space for children. These are fundamental if ambitious urban migrants are to be satisfied and thus not violent, and are to be economically productive.

Where is the Medical School bold enough to find ways to enable its students to look at the health care needs and the indicators of health in the flood of urban migrants? And then to help to do something about those needs. Imagine a State or a Federal Health Service staffed by those who, in their impressionable student years, had had the privilege of breaking such new educational and practical ground. When the Gondar.

Public Health College in Northern Ethiopia began in 1956, its student Health Officers worked within the Gondar municipal health authority, alongside its staff .. They served as they learned. Later this admirable apprenticeship was stopped by a new Director who therefore denied his students a wonderful apprenticeship. This great country Nigeria is the home of African entrepreneurs: Please allow me to ask – where are the educational entrepreneurs for the health of those who live in the slums?

The present data on health in slums are limited but the few publications in Africa are frightening and show a lack of services, violence with no-go areas, and unacceptable health indices, like maternal mortality, reported in a 2017 paper from Lagos as 1050/100,000 live births, whereas the Lagos State rate was 545/100,000. Neonatal mortality at 18.4/1000 and under 5 mortality at 103/1000 add to the misery. The authors comment that inequities among poor, remote, vulnerable populations can be revealed if regional and disaggregated data are collected.

Poor slum living keeps people in poverty; is this one of the reasons why the rate of poverty in Sub-Saharan Africa is growing? Lessons learned have to be applied in society. To apply is inescapably political and may be decidedly uncomfortable, as is any analysis of poverty, which has crushing effects on health.

Poverty

I said at the beginning that we have an uncomfortable subject today. A recent analysis from an academic from Jos, Zuhumnan Dapel, now in Washington at the Center for Global Development, is important. I wish that I could ignore it, but I cannot because he states that his data are significant for health.

He analysed the household surveys for Nigeria between 1980 and 2010, and used the cost of basic needs, CBN (food to give 2,100 calories per day and the cost of basic essentials, shelter and clothing). Those who escape poverty will have a daily income of N 209, while those who will not it is Nl13. Let me quote the policy conclusions of his paper in full. He writes: “The poor have not experienced significant growth in their average living standards despite some moderate rise in GDP per capita over the past two decades. Thus, I found growing evidence suggesting a rising deep level of deprivation in Nigeria, rendering more than two-thirds of the poor at risk of spending their lifetimes below the poverty line.

The clear implication is that growth has not been sufficient nor has it demonstrated the potential to help the poor break free from poverty. This calls for policies that not only bring about a rise in GDP, but also boost the income growth of the poor. Like Brazil, Nigeria can achieve significant poverty reduction without absolute reliance on economic growth by reducing its two-digit inflation rate and substantially expanding its social security and social assistance transfers. Finally, improvements in life expectancy as a health outcome can also improve the chances of the poor of escaping poverty: longer lifespans could shrink the gap between life expectancy and the duration of poverty spell. Unfortunately, Nigeria does not have universal health coverage, which would benefit the poor by making healthcare more affordable.

Africa’s Health, Population and Climate Change I spoke earlier of the threats that faced Africa’s health.

They remain formidable and are recognised widely as in the recent Gavi analysis.

When we worked in Zaria the 1973-74 drought savaged the Sahel and the northern guinea savannah; camels, horses, goats and sheep died, proud Tuareg men came south to survive and were reduced to becoming night guards. I went with students not far north of Zaria and saw, in a dried river bed, how a cattle boy was digging deep to find a little water which might seep into his calabash. The price of sorghum, dawa, went up and up.

Some people north of Kano were reduced to eating leaves off trees. Now, desertification is worse and the population has more than doubled. I do not need to remind you that Lake Chad has shrunk catastrophically, and its basin which was wet, is dry.

Food is less abundant. Maps have been published which show how vulnerable much of West Africa is now, conflict and a loss of security have compounded undernutrition. Internally Displaced People, the lOPs, are pitifully vulnerable. Their needs will stretch any health service and will almost certainly lead to children missing school and essential vaccinations. The UNHCR published earlier this year a sombre map which snows the numbers and the places where refugees, now lOPs, are concentrated. I ask, are the medical schools, are the master’s courses, making students both aware and equipped to serve their fellow countrymen and women in such areas of crisis?

What an opportunity for some brave person in a brave institution to confront this problem and prepare courses which link service to the displaced with a rigorouS academic analysis and reasonable academic recognition.

An important book published last year, Making frica ark, of which our chairman today is one of four authors, has a quotation from the Governor of Borno, Kashim Shettima. It reads, by 2020 1/ igeria will be at million people, by million, making it the third most • million, and by percent of igerians populous country in the world y then will live in orthern igeria, with its cocktail of desertification, youth unemployment and low output here is no part of the north immune from this madness.

He also states that  “underneath aka aram is the cause etreme poverty quoted the work from household surveys and the geographical analysis of Zuhumnan Dape\. He studied the relationship of household size to poverty and showed, again very uncomfortably, that the northern States ranked highest in botn household size and domestic poverty. Forty years ago Helen and \ gave years to push forward education in the North, we have trusted and old friends in Adamawa, Bauchi, Nasarawa  and Zaria, but Oapel’s analysis is sobering. Why has progress been so slow?

Final thoughts \ have tried in this lecture not to pass judgment, but to draw lessons and conclusions from the recent work of others. I said at the beginning how much Helen and \ owe to Nigeria, we greatly value our association with the country. Africa is the . continent of the zi” century and this great country is its most dynamic. As friends of Nigeria we want it to lead and not to lag behind.

\ know that there are women and men, think back to Ebola, who have responsibility in health, and also in those areas which govern its social determinants, who do not seek their own welfare and advancement, who want to contribute to the common good and who respond, as John Wilson did when he was a young but blind man. Let me quote him again -liAs we left those villages I felt sick and angry and was possessed with the urgent need to get something done about the situation”.

What more appropriate way to celebrate the life and contributions to Nigeria of Ladipo Akinkugbe than for some here, or some who cannot be here today, to be possessed with the urgent need to get something done,  done for the poor, done for those who live in slums, which will inspire today’s young professionals to use their life and skills to promote

Africa’s Health, and set an example beyond Nigeria’s borders to men and women of great heart, who are ready to spend and be spent in service. Thank you.

Being lecture delivered by Sir Eldryd Parry at a ceremony to mark Emeritus Professor O.O. Akinkugbe’s “Hanging up the Stethoscope” on Thursday, October 25, 2018 at the International Conference Centre, University of Ibadan.