How do we fix our health system I?

This is the first part of series of personal reflections on how to address the problems with our failed health system based on critical look at current efforts and empirical observation of real places. What we need is not more hospitals, health workers, medicines, technologies or medical equipment but rather (1) a set of mutually agreed values that govern our relationships and safeguard our rights outside our immediate families, and (2) a set of agreed ways of enforcing our agreements. Some key institutions have tried to play this role in Nigeria with limited success. I will comment about a few starting with what dominate our discourse especially on social values in Nigeria – religion.

Religion has failed to provide these guarantees at least in the geographical location named Nigeria! This may not be a problem with religion per se but with how it is interpreted/perverted and practiced. That someone is religious or appears religious does not mean they understand the religion and therefore there are no guarantees that their actions will be guided by the true spirit of their professed religion. No need for examples here as all would have been betrayed by one man of god in the past or at least would have read or heard of several incidents of such. You may also think of some trustworthy atheist that you may have interacted with. So religion may not matter that much (I will return to the role of religion in the second part of this essay).

Neither have race, region, ethnicity, tribe nor clan guaranteed that your dealings are secure in this our seemingly stateless existence. Here again I will leave you the room to fill in the examples of the betrayals/broken promises from people you might have thought you can identify with on the bases of these categories. One needs to look no further than the fuel subsidy scandal to make up their minds.

Political parties were expected to play this role in our own version of democracy but we have yet to evolve such political parties in Nigeria. There are a few trustworthy people in all our political parties including PDP and there are many dishonest people in all of them including the opposition ACN, CPC, ANPP, APGA etc. Here again examples abound. Yesterday it was 200 cars for first ladies summit. The other day it was some wives’ of legislators from an ACN governed state attending course on ‘spouse support’ (whatever that means) in the UK on state’s resources. We do not need to mention the absurdity that is state sponsored pilgrimages!

Agreed, it is impossible for everyone to sign up on a set of moral principles, but it is very likely for a significant numbers to agree on a minimum set of principles that safeguard life, property, dignity and livelihoods (basic functions of state not provided in Nigeria). These are all we need. This significant numbers can also agree on mutually enforceable systems and work to actualise them at least among themselves and any others who want to deal with them. The need for this system is extremely urgent and it has happened even in places that have seen the worst forms of social turmoil. I will use the example of the poster child of statelessness – the modern Somalia.

To an average outsider Somalia is hell on earth. Well, Somalia is no paradise, but you may be surprised that the country enjoys higher economic growth and health and wellbeing in recent years much more than in the period preceding the dissolution of the state in 1991 and its performance on some key social indicators are far better than or at par with most countries in sub-Saharan Africa including our dear Nigeria! For example 20% of Somalia has piped water in 2010 compared to just 4% for Nigeria for the same year (Source: WHO/UNICEF JMP 2012). While this is sadly worsening for Nigeria, in Somalia it is actually improving. In the same report and this should shock you because it is about nutrition where Somalia is synonymous to famine, drought and malnutrition as painted by international media. Nigeria and Somalia are almost level at 41% (2008) and 42% (2006) respectively for children less than 5 years who are underweight! Taking into account the trends in the two countries one wonders who is ahead in 2012! These averages also mask the wide regional and socioeconomic disparity which is much bigger in Nigeria than in Somalia.

Somalia returned to the traditional Xeer (pronounced - hair) system following the collapse of the state. This system is based on clan groupings (Diyah groups) and the enforcement of rights is true restitution which is binding on all members of the clan shared proportionately. If a member of clan x steal a camel from clan y, then every member of clan y will contribute to procure two camels that will be paid back to clan x. If a member of a clan becomes notorious beyond control of the clan elders and keeps on offending, such member may be rejected by his clan (excommunicated) and therefore lose all protection, a very precarious situation indeed which is avoided by most. This is a caricature of a complex system but those interested in more details can research further. This system has enable industry and productivity in an area that would have otherwise descended into chaos (if Hobbesian theory about the natural state of affairs holds) without any functional central government for over 20 years now. There are other examples such as burial societies in most of rural Uganda after the cattle raids and the long periods of violence that followed (more on the Uganda example can be found in the book by Ben Jones - Beyond State).

To make these points relevant to health, think of the things that damage our health in the communities we live in: sanitation, potable water, housing, peaceful, secure and serene environment etc. All of these require us to relate with others in order to meaningfully have them. Imagine if your neighbours decide to direct their effluents towards your house or turn your front yard into their refuse dump what options do you have? You may want to fight them – physically or through the authorities (depending on your physical or financial power), ignore/bear with it in the interest of ‘peaceful’ coexistence, or clear it yourself if you cannot bear and have the means. These are not hypothetical scenarios. I have seen several and had conversation with a few people living in these kinds of situation. I will like to share one:

A few days ago I interviewed a man living next to a mountain of refuse in an informal settlement that has developed very rapidly compared to when he first moved to the area about 30 years ago. Few years back, there were plenty of empty ‘neutral’ lands where people could just walk to and dump their refuse but as the area is increasingly built up, the few places left undeveloped are turned into dumpsites. And because they are fewer and fewer and serving more and more residents the places fill up quite rapidly. This particular refuse place is an un-built piece of land owned by another person who was approached to sell the place for N2million (a handsome amount for most residents of the area) but he refused because he is working to get enough money to build so he can move in with his family. The key concerns of my interviewee are that the refuse get scattered by wind and messes up the whole area and rain water washes off dirt from the place into the surface water. Since most residents in the area rely on well as their source of water for domestic use, the dirt ends in these water sources, contaminating them. Another concern was that of smoke from regular burning of the refuse which sends offensive odour and pollutes the air in addition to loosening the soil that renders their buildings weak with risk of collapse. My interviewee was however not willing to force the owner to sell because he thinks if the owner had the money he would have developed it and moved out of the rented flat where he currently lives with his family. After burning, the refuse shrinks and the remnants are bagged by children and sold as organic fertilizer to farmers. But this is not enough to clear the site as the rate of clearing cannot keep up with the pace of dumping.

Where do you begin to address this problem from? In our increasingly individualist society, the neighbours could not stop people from dumping because it is not their property. Stopping people by force may result in conflict which no one wants to add to their list of unending troubles. The owner could not stop it because he does not live near the site (Even El-Rufai of fame had to build fortified barriers to prevent people from accessing the green areas in some places in those days, imagine what it will mean for a poor person). The situation calls for some form of mediation which in normal places the state will come in. This is no normal country and that is why such a place exists in the first place. Calling in the authorities in our current situation at best can result in forcing the owner of the said land to sell it off at price that is below market value if it has to be immediate. A possible outcome is that a richer person that can develop the place will buy it and possibly develop it or just fence it and leave it to add value for him. This was not acceptable to my interviewee who empathises with a fellow poor man to the detriment of his and his family’s wellbeing. He told me during the interview that he just recovered from a bout of diarrhoea and vomiting that required admission at a high cost for him and that there is no month that will pass without a member of his family falling sick with the consequent strain on his meagre income. Will this approach have made the refuse to go? NO! The result here in the long run is just shifting the refuse to yet another newly developing neighbourhood as the first owner may collect whatever amount he was able to realise and buy another piece of land in another cheaper informal development where the initial problems are now recreated. Another possibility is that civil servants will force the owner to pay some bribes to avoid revocation which will set him backward in his plan to develop the place without addressing the problem at hand.

What if the community had a system that mediate relationships which is mutually agreeable to all the actors? No one will violet another’s right because they are protected and penalties are enforced. Therefore, no one will dump his refuse in another’s property without consent. Such system would have created an alternative way of collecting refuse and even a way out for the owner of this land to build a house for his family. There would have been a cleaner environment, another family in their own house living peacefully with their neighbours. All these would have improved their health and wellbeing without spending any kobo on hospital or medicine.

The second part of this essay will look at the major ‘social worlds’ that govern our current health system and some of the potentials they offer. These include: the receding traditional institutions; the legitimacy-seeking state; the highly influential but misapplied religion; and the ineffective but growing individualism.

26/07/12

Why we don’t want to understand what killed a man and woman in a car in Kano!
The recent death of a couple in a car in Kano highlights yet again one of our cultures in Nigeria of not wanting to investigate death. For some odd reasons in our society we do not want to conduct full autopsy to find out the cause of death even if the circumstances are unusual and even when it is obvious that there is 

some foul play. Not to mention contemplating legal action, this would have been considered a serious sign of faithlessness. We simply rationalise it as God’s wish. Chief among the reasons for this especially in the North to me is the fundamental misunderstandings of Islamic position on such investigation or reluctance to follow its guidance because of our stronger cultural views about death. As result homicides go undetected, avoidable deaths continue to occur and culprits go scot free.

It is understandable that emotions around death are strong and people dislike that their loved ones are not giving the ‘appropriate’ rites including it been done in time. There is also pressure from family and friends to leave things with God and not heeding to such counsel would have been judged as sign of weakness of faith or some form of disbelief. Everything around death presents a very strong need for closure and the longer it is investigated the more severe the emotional burden. However, again it is this same reason that should necessitate appropriate investigation to determine the cause, culpability and preventive measures. I think we can achieve true closure and the death would not have been in vein if it serve to prevent another’s loss.

How many homicides occur from road traffic accidents, professional negligence, industrial errors, environmental damage etc. without us knowing the cause and where fishy anyone being held to account? I will highlight some high profile cases that only became apparent to us when someone from outside had to wade in for us to understand what happened and for ‘victims’ of one of this cases to have some hope of restitution. The drug trial in Kano by Pfizer during the 1996 epidemic of meningitis that resulted in death and some impairment among children came to our attention only by December 2000, when The Washington Post published the result of investigation going on in America. Similarly, the worst lead poisoning disaster in recorded history, killing approximately 400 children in March 2011 alone came to our attention only because some doctors from the humanitarian organizations Medecins Sans Frontieres ("MSF"), also known as Doctors Without Borders decided to investigate. We would have simply continued to bury the death and do what we do for the impaired for only God knows how long.

I find the belief that investigating the cause of death as a sign of lack of faith absurd and the reluctance to hold people ( lay or professional) and institutions to account when liable even worse. I am not an Islamic scholar, however, I find it hard to reconcile why God will prescribe punishment for homicide and even detail compensation and how such should be dispensed with not wanting to hold the guilty party responsible. Investigation therefore becomes a matter of necessity since you cannot ascertain blameworthiness without it. My reading of this is that there is nothing wrong in investigating a suspicious or ‘mysterious’ death. It is mysterious only because we fail to investigate. If we do not learn from events, I do not see why this should not happen again. Or maybe we just wait for MSF to unravel this one too!

Investigation of death is the bread and butter of medicine. A lot of the medical technologies we take for granted today come about because some people try to find out what is killing them and do something about it. To me there is no difference between taking medicine for a fatal illness and finding out the cause of death of someone in order to prevent similar event happening to someone else, same with prosecuting negligence to avert another person’s grief.

In the case of ‘Man and woman found dead in car’ by Dailytrust (23/05/2012), even though medical knowledge have availed us with the means of knowing with greater degree of certainty why the couple died, a lot of what we know are mere speculations. We probably will never know for sure what really happened because we are not going to do a proper investigation. The excuse that the bodies are already decomposing so we cannot do proper autopsy is not acceptable. There is at least one theory that the death could have resulted from carbon monoxide poisoning. I am not a pathologist but surely two days after death there are chemical test that can at least exclude this. Leave the bodies aside, what about the car itself? Was any test done to assess the composition of the air in the car when the bodies were found? Are there investigations about other possibilities of other toxic emissions from the car? What are the similarities between the two recent incidents? I am not referring to the similarities that most women will want to observe! Lol! What if it is something we put in our cars every day, maybe some unwholesome car fragrance? There are lots of possibilities, but with intent and professional handling this can be unravelled and possibly save some lives in the future.

Generally, I think we need to be more serious about trying to understand things that are killing us.