Summary Report On Health

Mission, Year 2002 To Nigeria.

By Felix A. Onyeise, MD, MS.

Introduction:

The ever-increasing morbidity and mortality among people of Africa is well recognized among the medical community in the Western Countries. The average life expectancy of a Nigerian dropped from 53.6 in 1998 to 51.6 in the year 2000. In the United States, the average life expectancy rose from 76.1 to 77.1 in the same year period. Figures for some other countries are as follows from the year 1998 to 2000: Andorra 83.5 to 83.5, Angola 47.9 to 38,3, Cuba 75.6 to 76.2, Ghana 56.8 to 57.4 Japan 80.0 to 80.7 and Cameroon 51.4 to 54.8. (US Census Bureau's International Data Base). On the average, African countries continue to experience down ward trend in life expectancy at a rate of an average drop of 1.5 years per every three years. It is an alarming paradox to have life span of Africans to be dropping precipitously in a century in which major advances in science and technology continue to escalate. Africans also do live the most deplorable quality of life. The masses live painful short life before dying very young and painfully also. In the past few years, Sunicef Healthcare International, a not-for-profit and non-government organization (NGO), has been working to ascertain and quantify the causes of this disturbing disparity.

Nigeria is the most populous and likely one of the most endowed with natural wealth in Africa, hence it was chosen for the search of causes of high morbidity and mortality. Several locations are being studied but this summary is focused on activities in Amumara, one of the pilot locations. This is an ongoing intervention study whereby findings are expected to inspire the leaders for action. In this brief summary of the major findings of health mission 2002, you will be acquainted with reasons why Nigerians continue to experience low quality of life, high morbidity and mortality

Diseases and health conditions responsible for high morbidity and mortality.

In the past, and still presently, some people (including health professionals) do believe that certain health conditions afflict only people of the western countries. Cancer is one of such diseases. But we have seen cancer of all organs in Nigeria. Some health conditions may be endemic in one area, while others start in a certain location but eventually spread to all areas. The human body is built with the same building blocks much as houses are built with the same materials but have different shape and height. Consequently, the human body, no matter which country it resides, is prone to develop the same illness when subjected to the same trauma, stress or infectious agent. It is not surprising therefore; that what we found in Amumara and true of Nigeria, is that the leading cause of morbidity and mortality is the same there as it is in the western countries. These are hypertension, heart attacks, stroke, prostate cancer, bronchitis, emphysema, diabetes and HIV/AIDS. There is no available data on breast cancer but we do believe that it is also a major contributor for high morbidity and mortality. At least two cases of breast cancer were previously documented in Amumara. Both patients have long been deceased. Other conditions are responsible for high mortality (malaria and typhoid) and morbidity (filariasis hemorrhoid (pile), pneumonia, anemia, and malnutrition) in Nigeria and not in the west. Other common conditions causing chronic debilitation, especially among the elderly, are arthritis of all types, carpal tunnel syndrome and cataracts.

The perinatal morbidity and mortality is one of the highest in the world. Sadly to say that the main cause of death for reproductive age women in Amumara is pregnancy related complications and not HIV/AIDS as conventional media report of this pandemic may suggest. At least one out of every four pregnant women dies in childbirth. In Amumara two such deaths have occurred since my return early this year.

For those conditions responsible for high morbidity and mortality in Nigeria and Western countries, morbidity and mortality are highest in Nigeria. Patients with these high morbidity and mortality conditions (hypertension, stroke, heart attack, diabetes and HIV/AIDS), die younger in Nigeria than in the west.

Reasons for higher morbidity and mortality by the same health conditions in Nigeria than Western countries.

Health care knowledge deficit is the most important reason for the high morbidity and mortality in Amumara. Linked to this is the health care belief system that is rooted in superstition and suspicion. This does not imply that our people are not highly intelligent or knowledgeable in many other areas. Most of us know many teachers of different fields of study with multiple degrees in Nigeria. These same intellectuals would assert emphatically that high blood pressure is caused by a poison or invoked spirit against them by an enemy.

Stroke and heart attack are equally explained the same way, so does arthritis (acquired by stepping on a poison in the farm) placed by an enemy.

The sad implication is that most sick people would go to native doctors and prayer warriors before seeking proper medical care. Usually, the window of opportunity is already lost, and the patient is either at terminal stage or has sustained permanent complication.

Self-diagnosis is a serious dilemma. It is not unusual for a patient to go to a doctor and say, "I have malaria". Surprisingly some doctors would actually give a prescription for malaria without further investigation. A patient could say to a family member " I have headache". The response would be "you have typhoid", and then the patient is told to go buy chloramphenicol. Chloramphenicol is a prescription drug, which should only be used under the supervision of a physician. Even when used appropriately this drug could cause more fatality than typhoid because of its adverse effect of bone marrow depression. Recent medications which are more potent and less toxic for treating typhoid is available but not known to health professionals due to

lack of continuing education.

Igbo language lacks vocabulary equivalent of some English medical terminology. The other 250 languages and dialects spoken in Nigeria are possibly devoid of many crucial vocabulary equivalents of English medical terminologies. As a result, patients do not adequately communicate what they feel to the nurse or doctor. Patient history is the core of medical diagnosis. A physician is guided by the history a patient provides. If the history is wrong, the physical examination would also be misguided and the diagnosis would invariably be wrong, so would the management. Admittedly, I do not know the Ibo equivalent of all the parts of human body. What is pancreas in Igbo? What is apa-afor? What is oke ehie? I think oke ehie is fibroid. This creates a very challenging communication barrier between patients and health care workers.

Misuse and abuse of medications is another major contributor to higher morbidity and mortality. In the first place most medications in Nigeria are adulterated. They do lack their stated potency and efficacy. All medications are over the counter. Self-prescription is the norm. Drug side effects, drug-drug and drug-food interaction are not observed. Two or more family members or friends suffering from different illness share same medication strictly out of kindness or expression of love.

Lack of medical supplies and equipments is universal. Most clinics do not have reliable thermometer and blood pressure kits. Laboratory test are extremely unreliable. Most nurses and even doctors lack personal basic working equipments but wear expensive shoes and artificial hair of several Naira value more than their basic working tools. Usually they are quick to say there is no money and ask those in overseas to buy it. My response has always been that, I never saw my father go to the farm without knife and hoe. At least they could buy basic things and we can work together on ultrasound and x-ray machines etc. An average Nigerian is under the impression that there is a dollar tree in US, which is easily accessible to anyone living there. Unfortunately we have inadvertently reinforced this erroneous belief.

Paternalistic model of medical and health care is the dominant practice and has its attendant adverse consequences, of which, patient alienation and none or poor compliance by patients are obvious ones. Doctors and other health care providers seldom communicate effectively with the patients. Patients are not told what they are being treated for, name of the medications they are prescribed, potential side effects, drug-drug, drug-food, drug-disease and drug-co morbid interaction. In essence, patients have to accept what ever was presented to them. Patients are seldom encouraged to ask questions. As a result of lack of resources, sadly so, some of the health care providers do not know all the documented potential adverse effects of some medications.

Lack of health professional continuing education is an important barrier to adequate patient care. Health professionals are what is known as "dated professionals", meaning that, all they know is what they learnt in school and what ever experience they acquired at work. They do not have access to recent advances in their fields.

Some modifiable risk factors predisposing to acquisition of the health conditions responsible for the high morbidity and mortality.

High blood pressure (hypertension) has stroke and heart attack as its major complications. Diabetes also leads to stroke, heart attack, blindness and loss of sensation in the extremities as its complications. In both conditions high cholesterol is a risk factor. High cholesterol leads to hypertension. Excess alcohol also leads to hypertension, diabetes, and many types of cancer. (Elaborated in: Alcohol: a drug that kills to be published soon). Excess cooking salt intake will also elevate or sustain elevated blood pressure.

The major source of cholesterol in the diet of some one in Amumara is palm oil, palm kernel, coconut and meat. In the United States and other western countries, type 11 diabetic is said to be due to excessive body fat. Patients of type 11 diabetes in these countries are about 10lbs or higher over their ideal body weight. However, in Nigeria type 11 diabetes patients are on the average under their ideal body weight. I therefore, do speculate that, there may be a link between excessive carbohydrate intake and diabetes type 11 in Nigeria. You may ask, why don't everyone one in the family get it? After all members of the same kitchen in Nigeria eat almost the same food daily. Well, there is a genetic predisposition (not quite scientifically delineated), which members of the same family inherit unequally.

Cigarette smoking is another health risk for hypertension, cancer and other neurological diseases. Marijuana (guff) and crack cocaine are in wide use in Nigeria.

Sedentary life style is not the norm. People do walk around for the most part for all they do. As a result, sedentary life style as a major risk factor for heart problems in western countries may not be applicable to Nigerians yet. However, the affluent in Nigeria live mostly sedentary life-style (uses car), and this may explain the higher prevalence of heart problems in this socioeconomic class. Stroke also seem to be more prevalent among retirees in Nigeria. We are not sure of the significance of this link but speculation is that psychosocial stressors may play a role.

What activities took place in Amumara during this health mission 2002.

Health education and counseling were conducted as seminars, in small groups, on individual basis and in some families. The following were addressed; HIV/AIDS prevention, moderate use of alcohol, stop smoking, moderate use of palm oil and coconut, use of balance diet, sources and role of vitamins and minerals, importance of prenatal care,

risk of self-diagnosis, self-prescription and stress reduction.

Patients with specific health problems were seen on individual basis. Follow up referrals to their home physicians was recommended. Most patients easily experienced the difference in efficacy of American medications. Conditions said locally in Nigeria to be caused by poisoning but known medically in the West to be bacteria infection were adequately treated with appropriate antibiotics. For instance, a woman said to have "nsi agba", a poison credited to Ngwa people was treated with an antibiotic. This did cast a widely accepted doubt on nsi agba as a poison. Six other people with similar conditions were treated. Some stroke patients were brought as victims of "Ala Ogbaga of Chokoneze". These unfortunate patients supposedly cheated someone of their property; hence the cheated went and complained to Ala Ogbaga. This revered arbiter spirit of the yonder world does not waste time in avenging wrong by causing sickness, which invariably leads to death. In acute attacks the victim dies instantly. Thus, Ala Ogbaga could cause both acute and chronic illness as the belief goes. The story goes on and surely most of you know it better than me. However, a thorough neurological examination of these patients showed findings reminiscent of similar patients in United States. Under specialized post stroke management, some of these patients are defying their expected length of survival.

Five families in Amumara with their children in USA were randomly picked and paid a home visit. At our request medications sent to them from USA by their loved ones was brought out. The medications seen were of four categories: antibiotics, analgesics, anti-hypertensives, and diabetic medications. Only one family, out of the five, was able to identify correctly how to use the medication but did admit it was not being taking at the recommended frequency. Two or more medications for the same target symptom were being taken as different medications. What prompted this mini study was a documented two cases of fatality due to misuse of medications sent from USA to family members in Nigeria. Though neither of the two cases occurred in Amumara, the potential as evidenced by the findings in this study does exist.

A collaborative initiative between Amumara Comprehensive Health Center (ACHC) and Sunicef Healthcare International (SHI) was established. I met with Mrs. Ikpemo, Ewunonu and Eunice Osuji. We toured the Center site and identified that facing it is of imminent need to secure the building, which already is being vandalized. I did promise to communicate this need to

ADU-USA branch. On behalf of SHI, I did pledge to continue as a technical resource person for the center.

I also did meet with the staff of Amumara dispenser. Their needs are the same as those of other health facilities in Nigeria. They lack basic equipments and supplies. I donated supplies worth $3000.00, collected and signed for by their Nursing director, Mrs. Ikeojuo. It is hoped that the dispenser would merge with ACHC when it goes into operation. SHI will continue to provide the staff of the dispenser ongoing continuing practice education. They will be receiving free literature on advances in treatment guidelines.

Recommendations:

It is recommended that anyone sending medications to loved ones to Amumara both prescription and nonprescription, should ensure that accurately and legibly written patient information about the medicine is included. The insert in the bottle of some medications and written information on bottles or packages do not substitute for complete patient information. Medication inserts are for doctors and in some cases, pharmacists who possess the technical knowledge to interpret them. Written information on bottles and packages are usually not complete. If contacted in advance, I would be of help to provide patient information on any medication both prescription and over the counter (Sunicefhealth@Juno.com). It is important to note that over the counter or nonprescription label does not equate to innocuous. All medications are potentially harmful when used as not directed.

Encourage your loved ones at home to go see a doctor, not nurse, chemist, or laboratory man at first sign of symptom especially if it persists for some days. Those with diagnosed hypertension must check their blood pressure at least weekly, see a physician once monthly, take their medications as directed and your greatest gift to them would be a blood pressure kit.

Persisting headache or recurrent headache calls for blood pressure monitor over several days to rule out very high blood pressure that could lead to stroke.

Imo State University: Departments of Igbo studies and medicine, have been advised to work jointly to provide appropriate Igbo vocabulary equivalents of all English medical terminology. It was father suggested to the departments to start with a publication of Igbo anatomy book, with complete listing of all human body parts in Igbo.

Personal Thought:

It is my vision that "a comparable life span in the western countries is attainable in Nigeria and other African nations, if currently available health care knowledge, supplies, information and other resources are harnessed and applied to the communities". I also do realistically adopt the notion that it will take a genuine and sustained selfless commitment by the citizens of Nigerian communities of different socioeconomic levels, irrespective of the current country they reside, to contribute individual talent for the reversal of this dismal down-ward trend in their life expectancy. It is a clear illusion for we Africans to keep hoping that members of the Western countries will improve our community's health and life expectancy.

We have copied correctly how to dress, eat, speak and drive cars like the people of the western culture, but have failed to copy the management, working and health ethics and skills responsible for their ever- increasing quality of life and life span. I do believe that the Creator does not disperse people into the world at random. He most likely do look at the need of each community and then put talents there to meet those needs. For us to be attracted to and live permanently to the places of our current residence is to deprive our community of talents needed to meet their needs. It is not quite enough to be sending money to loved ones at home. Many of them have become dependent on what they receive much as public aid recipients in USA have lost their ability to fern for themselves. Most of us came to the west with the original goal of acquiring technical know how and take it back home to improve our communities. It seems that we have lost sight of this goal blaming it on changing conditions at home. A clear vicious cycle has emerged, whereby we are waiting for conditions back home to improve when we seem to hold the only key to improvement of the conditions. The amount of money we have sent home individually and collectively so far has not changed anything. This strongly does indicate that the money and the know-how are running parallel. We possess the know-how and we are to implement it. Our physical presence is needed in the community, at least partially, at a reasonable interval, to demonstrate and instill the know-how paramount in effecting any changes. This is the only sure way to change and improve conditions in Amumara. History would bear me out some day that; there would never be a significant and sustained health or economic revolution among Nigerians until a mental revolution is attained. Financial shortcomings are not the main handicap in deteriorating conditions in Nigeria. Misappropriation of the little available is a major problem. It may sound down grading, but it seems like we need to think for people at home. No one can give what he does not have no matter how much he desires to do so. The core of most problems facing our communities at home is rooted in their belief system. To achieve any positive milestone in the quality of life and conditions of living of our community require transcendence from current ways of doing things to the proven ways of western ethics. It is no other than us who have experienced the Western self and community preservation experience will carry the message to our communities. For many years our predecessors have practiced "if you can't beat them, join them". Consequently, living conditions have stagnated and in some cases, like health care and education continue to drift backwards.

Future Plans:

The 2003-year mission is being planned now. You are encouraged to give your input and suggestions. Work will continue on intense public education addressing all those areas previously mentioned. The educational program is dubbed HOPE (Healing Our People through Education). Prevention and wellness is of primary importance. We plan more extensive screening for hypertension, diabetes and high cholesterol.

The Safe Motherhood Initiative Program will focus on perinatal health issues. Detailed culture sensitive guideline for prenatal care will be introduced. The need for prenatal care, role of prenatal vitamins and minerals, it's sources both local and foreign made pills will be provided. The concept of risk pregnancy and the role of changing economy and culture will be discussed.

Menopause and its attendance anxiety provocation will be detailed. This is a major problem for elderly women who are aware of the changes their body is going through but ignorance of the true medical significance of it. They tend to spend significant amount of time and financial resources on native doctors and churches seeking an elusive relief.

Mental health illnesses are as much of a problem in Nigeria as it is in the West. As stated earlier about physical illness, the human body responds the same way to the same stressful conditions, be it in the west or Africa. Both emotional, spiritual and mental health problems are rampant but not recognized and addressed. At best, all their problems are addressed spiritually. Anxiety and depression, persistent grief, alcohol abuse and dependence, schizophrenia etc is all over the country. One major source of anxiety is infertility. We hope to address as much of these problems as possible using culture specific approach to dispel the superstitions clouding the legitimacy of these health conditions. Currently, much of these mental problems are being attributed to ghosts of the yonder world.

Conclusion:

During the Health Mission 2002, it was found that some of the major leading cause of morbidity and mortality in Amumara, is the same as in the USA. With the noted exception of very high maternal mortality in Amumara and not in USA. The top culprits are complications of hypertension: heart problems, stroke, cancer, chronic obstructive pulmonary diseases (bronchitis and emphysema), HIV/AIDS and other infections. Chronic arthritis and carpal tunnel syndrome are major morbidity especially for the elderly. Comparatively, the same health conditions cause disproportionately higher morbidity and mortality in Nigeria than Western countries. Major reasons for this disparity is health care knowledge deficit, health care belief system rooted in superstition and suspicion, poorly equipped health care facilities, lack of health care professionals continuing education and paternalistic model of medical practice.

Identified modifiable risk factors are malnutrition and poor nutrition, unbalanced diet, excessive carbohydrate consumption at the exclusion of protein and vitamin and mineral containing meals, Excessive palm oil and alcohol use, self diagnosis and prescription, stress and poverty.

Of all intervention modalities, the most important and prerequisite is intense, culture sensitive public health education and health professional continuing education. Provision and introduction of medical and pharmaceutical supplies is also crucial to adequate and timely intervention.

All comments and questions concerning this report and suggestions for future Health Missions should be directed to Felix A Onyeise, Sunicefhealth@Juno.com and Onyx7@Juno.com.