CHILD HEALTH

The Dilemmas of Child Health Care in Tropical Africa Noel Guillozet, M.D., F.A.A.P.*

IN

MANY WAYS, the health problems of Cameroon typify the health care problems facing most countries.of the tropical Third World in Africa and of Central and South America. Cameroon has fewer than 250 practicing physicians, and at least half of these are borrowed expatriates who pass brief terms in caring for a fast-growing population of over six million. Fewer than half of the physicians are career nationals in the Government health service. Thus, the country has less than the 40 per cent of stable physicians, a threshold figure which Fend 114 has suggested as necessary for the stability of a service structure. With upward of 22,000 inhabitants per physician, on a national basis, and as few as 1 per 75,000 in some areas, physician coverage as we know it in the West is thin. Nurses and qualified medical assistants, who by necessity deliver the bulk of direct patient care, are also scarce. Compounding the health manpower problems are those of remoteness and of roads which are occasionally nonnavigable, and the many dif-

* Department of Pediatrics and Child Health, University Center for the Health Sciences, University of Cameroon; Department of Pediatrics, Harvard Medical School, and Department of Maternal and Child Health, Harvard School of Public Health. Correspondence to Noel Guillozet, M.D., % Dr. Charles A. Janeway, CUSS Campus Coordinator, 300 Longwood Avenue, Boston, Mass. 02115.

530

ficulties associated with unwritten dialects and tribalism. The United Republic of Cameroon had its beginning in 1961 with the reunification of the French and British Cameroons. Named for the enormous shrimp found on its Atlantic coast, Cameroon is a few degrees north of the equator and about one-fifth larger than California. Its annual per capita income is almost 180 dollars, well above the average for black Africa, but complicated by a fourfold difference between rural and urban dwellers. As in the other Nations in Central Africa, all agrarian and low income, it has a very young population and many infectious and parasitic diseases are endemic. With independence and the subsequent flurry of assessment of national needs, the Cameroonian Government with the assistance of the World Health Organization (WHO) studied the feasibility of setting up its own medical school. This seemed both desirable and practicable. By 1969, 40 students were admitted to study medicine in a newly created medical school affiliated with the University of Cameroon. In 1975, the University Center for the Health Sciences (CUSS) will have graduated 32 physicians, 17 laboratory technicians and sanitarians, and 21 postgraduate nurses in one of Africa’s most interesting

examples physicians

of team training for and paramedical staff.

generalist

health care professionals will responsible for Cameroon’s tropical population, of which an estimated half are age 19 and under. A scant 5 per cent are over 60. Along with a population growth rate in excess of 2.5 per cent per year, the infant mortality rate probably falls between 75 and 200 or more per thousand live births, as compared with about 20 per thousand in the more developed Western nations. These

soon

new

be

The Problems of Preventive Medicine: Nonexistence of a Public Health Structure

.

Village life in Africa, is similar to that in Asia, Central, and South America. Life centers around the land with its crops, rural traditions, festivals, and cycle of birth and death. More often than not there is a village well, but latrines are rare apart from demonstration zones and areas where Peace Corps volunteers have been stationed. In the larger towns, the water may come from a public hydrant but sewers are not usual and latrines are few and far between. Streams suffice for washing babies, children, and adults, laundry, dishes, and taxis. Not surprisingly, typhoid, cholera, amebiasis, and gastroenteritis abound. The dispensaries when present are jammed with babies ill with diarrheas and dehydration. Where the climate is dryer, as in areas bordering the Sahara, food shortages contribute to malnutrition and to health problems of varying character such as river blindness. Public health infrastructure as conceived in the West-a clean water supply and reasonably successful efforts to keep sewage out of it-are generally lacking. Malaria, bilharzia, filariasis, and other tropical diseases pose still other public health problems. The relative absence of basic public health programs and of potable water brings to the local dispensary, where there is one, many patients suffering from the same multiple diseases at the

time. Regular immunization programs offered by fixed health units to immunize against measles, whooping cough, polio, and other preventable diseases that tend to epidemicity and endemicity are few and scattered. Hence, many deaths from these diseases, where immunization programs have been set up for same

FIG. 1. Poliomyelitis. The Third World offers little for the man who cannot walk. These youngsters are in a rehabilitation center for polio victims.

rural

as in parts of Cameroon, vehicle failure, impassable roads, spoiled vaccines, and the limited services inevitable when urban-based teams attempt to serve distant areas. Further, these programs cannot perform on a two-year schedule what would have to be accomplished on a more or less constant basis, in order to control polio and measles in a population with a strikingly high birth rate (Figs. 1 to 3). Thus, the preventive medical programs allocated to immunizations and ambulatory preventive services for children during their highly vulnerable first five years have little functional structure and rarely receive as much as 20 per cent of the national health budget. Of the one to two dollars per inhabitant per year in the national health budget, half or more may be entirely consumed in curative efforts by a single major hospital in the capital city. The distribution of available health services in a tropical Third World nation can be very difficult. As much as 90 per cent of its population may reside in rural areas, but have only 10 per cent of the available physicians and a meager share of the health budget to care for them. The outcome of this maldistribution of inadequate resources and lack of a public health infrastructure is, not surprisingly, a low life expectancy. This is 41 in the Cameroon and even lower in other Subsaharan nations. An infant mortality rate between 75 and 200 or more per thousand live births has been estimated. Indeed, in many tropical nations as many as areas

founder



on

531

artistically placed scars from therapy that is, as likely as not, going to be continued concurrently with that prescribed in a dispensary or hospital. Such

FIG. 2.

Poliomyelitis.

Massive

paralysis

is

common

in

the first and second years of life in Cameroon.

one-half of all children may not survive longer than the first five years of life. one-third

or

even

Indigenous Medicine: Treatment of Choice



Western style medicine receives great competition from the well-established native specialists and generalists of all varieties. For example, in Senegal the marabout is a healer and religious figure whose role is hereditary. All these enjoy considerable esteem and are usually approached, often repeatedly, before Western medicine is sought. Government attitudes are often ambivalent. Thus Gandhi, when criticized for his support of traditional Ayurvedic and Unani practitioners in India, countered with his belief that it was better to have someone concerned with the medical and mental needs of the Indian people than no healers at all (India in the 1940s had a handful of doctors of Westernstyle training for a continually burgeoning population). Cameroon has its &dquo;gu6risseurs&dquo; and their advocates in government, yet virtually all of the latter are supportive of the University Center for the Health Sciences as well. Part of the anticipated profits from a newly established pharmaceutic industry are to be dedicated to research on indigenous medications being used by indigenous practitioners. Every day, Western-trained physicians in Cameroon are accustomed, even in the largest cities, to receive patients with multiple and occasionally fresh scarifications on the chest or abdomen or joints, at the sites of pains or swellings. Children frequently arrive with

532

treatment

of mental illness

seems

especially successful, and probably depends in part on the empathy and understanding of village and tribal customs by the indigenous practitioners. Their facilities are usually modest and native; no effort is made to replicate the eabinet médical of Europe or North America. They do not pose the apparent perils of a hospital with its unfamiliar treatments and efforts to keep relatives away from the other more subtle disof family and village customs. paragements In all the developing tropical countries, the estrangement of Western-trained doctors from the culture of the patients they must treat tends to be profound. It worsens in the rural and semirural areas which were least likely to have produced the young physician the bedside

or

FIG. 3. Tropical measles misery in a child who has lost 15 per cent of his weight through severe stomatitis and intractable diarrhea.

FIG. 4. Native medicine. A busy local healer specializing in head and belly pain, blindness, insanity, impotence, and tuberculosis.

in the first place, and which only infrequently offer the social, cultural, and professional contacts that he and his family tend to seek. As Fendall has aptly remarked, the Westerntrained doctor is an elegantly trained professional in an unelegant environment. In contrast, the indigenous practitioner enjoys many advantages in these nations of widespread illiteracy, tribalism, and rural traditions. He is closer to rural ways, more comfortable with them and often of the same tribal group as the patient. The indigenous practitioner has empathy, patience, and often a very good idea as to &dquo;who&dquo; made the patient ill-those ultrahuman spells, evil spirits, and the infraction of taboos which must be reckoned with (Figs. 4 to 6).

Traditional and

Major

Changing

Customs: A

FIG. 5. ~~ental illness is the speciality of this rural healer who offers residential care in his home for teenagers and adults.

indigenous

avoided. Neither can the desired industrialization which offers industrial and office employment for women. However, for the infant of the working mother in a society fraught with health perils, the loss of his mother’s direct care and breast feeding may prove fatal. There are scores of &dquo;useful&dquo; traditions. Among them is that of spacing birth intervals at two years or more, thereby permitting the baby to receive the breast through a critical growth period when dietary dangers abound

Health Determinant

Folk customs may pose serious problems the organization of simple basic health services and to the acceptance of curative therapy, and they may strongly influence the issues of nutrition and survival. J eliffe8 has divided these customs into three categories: the useful, the neutral or uncertain, and the to

harmful. Traditional ways, both good and detrimental, are increasingly influenced by the introduction of new goods, foods, improved transportation, urban living, and changing modes of employment. Modernization cannot be

FIG. 6. Exorcising the spirits, herbal treatments, and antibiotics are all part of this heater’s approach.

533

tion of the face and body performed with a razor blade on the young baby. These wounds invariably heal promptly and cleanly with no apparent deleterious effects. Customs which are &dquo;harmful&dquo; seem to abound. The &dquo;urge to purge&dquo; is a widespread characteristic of primordial health care. Enemas of red pepper or of the leaves of the manioc are popular in parts of West Africa; these as surely contribute to the deaths of already-ill infants as did the violent purgations utilized by Philadelphia’s more privileged citizenry in the late 1700s. Tetanus of the newborn following dirt or dung plasters on the healing umbilicus is frequent. Intoxications from indigenous remedies are com-

monly suspected in pediatric wards, and strange potions are frequently found by the bedside. Withholding of food and liquids from a child burning with fever or suffering from measles is customary in parts of Cameroon, and it is nearly unthinkable to undress and bathe a child having a 40 C temperature. Not surprisingly, febrile convulsions are common and the African child may convulse four to six times in his first two

years.

Avoidance of Malnutrition: The Health Dilemma Ftc. 7. Bottle baby: marasmus and its frequent cause. The difficulties and cost-of bottle feeding prove insurmountable for most.

in communities with low health standards. Another good tradition is the early serving of protein-rich foods-ground peanuts, cooked millet, and the like-and the assurance in some tribes that the baby receives the best diet in the home. The &dquo;neutral&dquo; customs are often colorful: the beads, bangles, and amulets to ward off evil spirits; the blackening of the eyes to ward off the evil eye, and a score of fetishes on the dressing of body or hair that are dramatic or odorous but have little to do with health. Circumcision that does not culminate in meatal stenosis seems relatively innocent although tetanus is occasionally seen. Tetanus is virtually never noted in what appears to be a particularly harmful and &dquo;primitive&dquo; custom, the ritual scarifica-

534

Traditions

impinge

most

Key

heavily

on

nutri-

tion, where perhaps their significance outweigh virtually all other aspects of &dquo;harmful&dquo; customs. Cameroon, more fortunate than many tropical nations, is blessed with a considerable variety of grains, legumes, tubers, fish, and sources of meat. Nonetheless, a large number of children whose parents could



afford a protein-sufficient diet fail to receive it and subsequently suffer from severe malnutritional states of which kwashiorkor and marasmus are the most dramatic. Many more have unrecognized malnutrition and suffer from protracted poor health, have measles of unusual virulence, and succumb to early death from an accumulation of diseases that a well-nourished child could have overcome. As a general rule, an infant deprived of his mother’s breast, for whatever reason, is likely to die from marasmus or diarrhea or both. For the young African girl of 18

plementary feedings to the maternal breast milk supply after five or six months, when the infant’s growth tends to outstrip supply. The promotion of &dquo;modern&dquo; ways and products such as the conspicuous advertising of bottle feeding and costly imported milks can be modified when a government wishes to do so. Less easy to alter are the dietary changes that follow changes in agricultural custom. Manioc, a starchy tuber that requires little attention and needs only to be dug at the farmer’s convenience for harvesting, is increasingly popular. The plantain, a bananalike fruit, is equally easy to grow. Neither manioc or plantain contain much protein, and this makes them dangerous to young babies and children who receive- them as staples to the exclusion of more balanced foodstuffs. Regrettably, in some regions these starchy plants are rapidly supplanting maize

Ftc. 8. Bottle versus breast. Nonsiblings of same tribe and family stature and ec~uat birth weight. Baby at left 5.1 kg at 13 months; at right, 12 kg at 8% months on supplemented breast feeding.

who has a baby of her own while she remains a student, the discontinuation of breast feeding may be the baby’s death warrant. The same holds true for the mother who responds to the lure of highly advertised powdered milk formulas (virtually no fresh milk) is available in the major cities of Cameroon and then discovers after her milk is gone that she is unable to afford the powder. Despite the best of will and the costliest of formulas, the baby is often victimized by a thin mixture of milk teeming with bacteria. Fuel for the boiling of water is scarce, refrigeration is infrequent, and the importance of cleanliness often poorly understood. In one rapidly modernizing capital city known to the author, 90 per cent of the infants under six months of age who were hospitalized with dehydration and diarrhea were bottle fed. Pernicious to infant growth is the often .widespread refusal to add protein-rich sup-

FIG. 9. Malnutrition. Twins at 13 months -combined with severe developmental delay. Unbreast feeding.

weight 11 kg supplemented

535

and millet which contain far more protein but need more farming effort to produce. Nothing short of incessant and intensive health education efforts, programmed successfully at village and urban levels, seems likely to alter the widespread infant and child malnutrition which continues despite the available and often equally priced adequate foods (Figs. 7-9). Existent Health Hindrance

Manpower: Help

and

From sheer shortage, and from the political imperatives of providing health care in

developing nations,

a

great many persons

FIG. 10. Error: Umbilical hernia repaired unneca medical assistant culminated in a wound abscess, tetanus, and death.

essarily by

FIG. 11. Error: Septic arthritis after two weeks of local treatment and phenobarbital given by a nurse with subsequent joint destruction and limp.

536

FIG. 12. Accumulation of disease: Malnutrition, multiburden.

ple parasitism, and measles pose a killing Hospitals contribute little to the solution.

FIG. 13. Priorities: A new

teaching hospital in the capital city. Jeopardy or boon to the future health of the rural masses? The site of training for rural service may be critical.

may be pressed into the delivery of primary and secondary health care without having been given the appropriate training to do this. Poorly trained and scantily supervised, they often work alone with infrequent physician support and contact. When a medical assistant, trained perhaps for two years, is confronted with an obstructed iabor, his choice may be either to perform a Caesarian section or to assure the patient’s death by having her transported to the district hospital 140 kilometers away over uncertain roads that may take a day to traverse. Incarcerated hernias, uterine ruptures, and major fractures are often faced bravely and well by nurses and assistants. Errors in judgment also occur, as in the management of the umbilical hernias so common in black Africa. These are often unnecessarily and unskillfully repaired, only to have the child develop a wound abscess and die from tetanus and peritonitis after being brought to the hospital in the capital city. Neonatal tetanus is too frequent. The late or inadequate management of severe dehydration in children leads to excessive death and complications such as peripheral gangrene or cerebrovascular accident (Figs.

10, 11). The difficult curative medical problems for children and adults will increasingly be brought to the superior skills of physicians as their numbers increase and their distribu-

tion to the district hospitals becomes more abundant and uniform. This will permit able medical assistants and nurses in dispensaries not simply to recognize the need but to refer the sick child to physicians for more com-

plicated

care.

Of far greater importance for children which can be

are

the services

organized and personnel far below

delivered in mass with physician skill levels. These fundamental services will reduce the difficult curative needs and dramatically lower the infant and child

mortality rates. These priorities include: 1) Village level surveillance of child weight, so that a defective growth curve can alert mother and health worker alike of malnutrition.

to

the

onset

2) Dietary counsel, to assure the proper solid foods when breast milk supply will no longer suffice or when early signs of growth failure become evident. 3) Widespread use of BCG vaccine to prevent tuberculosis in infants. 4) Administration of tetanus toxoid to pregnant women, in order to avoid tetanus in their newborns. 5) Organization of communities for receiving immunization teams when immunizations cannot be regularly provided at a health station. 6) Distribution of simple instructions for oral rehydration of mild diarrheas and for

537

health education, preventive medical efforts, and grass roots public health work priorities. Otherwise, without such priorities and the will to implement them, child health

the limited use of antibiotics as treatment for early pneumonia. 7) Provision of community health workers as enthusiastic promoters of interest in clean water, disposal of wastes, and good nutritional customs.

assure

Prospects for Children of the

References

Third World

The dilemmas of child health care in many developing countries have been barely touched by the technical accomplishments of modern medicine of the past 30 years. In fact, the accomplishments in many ways seem to imperil the reduction of the vast numbers of deaths in children from diseases which can be prevented at low cost. The more sophisticated are curative efforts, the more costly they become. Most of the newest drugs used in London, Paris, and New York are also obtainable in the capital city hospitals of Central Africa, South America, and Asia. It is in these major hospitals that the newer drugs and the bulk of doctors, cure-bent, will be found-and with them half or more of many a developing nation’s entire health &dquo;

budget (Figs. 12, 13). Malnutrition, diarrhea, pneumonia, and were well within the technical capabilities of 1950 medicine. Yet these still remain dominant health problems of children

malaria

in the Third World, making the mortality during the first five years of life 20- to 50-fold that in the more developed nations. It does not seem likely that the rapidly increasing dollar commitment to health care per capita in the more developed countries will be paralleled in the Third World. In many of the latter, the spending for health care is anticipated to rise only from one dollar to three dollars per inhabitant between 1970 and 2000. Nevertheless, much can be done with clear priorities and the skilled deployment of physicians and other personnel to

538

care

will remain

largely unchanged

and very

inadequate. Barns, T. E. C.: Rural services for maternal and child health. Tropical Doctor 2: 79, 1972. 2. Bennett, F. J.: Health education. In King, M., 1.

Ed.:

Medical Care in

Developing

Countries.

Nairobi, Oxford University Press, 1966. Health and the Developing World. and London, Cornell University, 1969. 4. Fendall, N. R. E.: Auxiliaries in health care programs in developing countries. Baltimore and London, Johns Hopkins Press, 1972. 5. Gordon, J. E., and Scrimshaw, N. S.: Infectious disease in the malnourished. Med. Clin. North Am. 54: 1495, 1970. 6. Hendrickse, R. G., and Sherman, P. M.: Morbidity and mortality from measles in children seen at University College Hospital, Ibadan (Nigeria). Arch für die Gesamte Virus Forschung 16: 3.

Bryant, J.:

Ithaca

1, 27, 1965. 7. Howard, L. M.: Three key dilemmas in international health. Am. J. Public Health 62: 73, 1972. 8. Jelliffe, D. B., and Stanfield, J. P.: Child health services. In Jelliffe, D. B., Ed.: Diseases of children in the subtropics and tropics. London, Edward Arnold, 1972. 9. Joseph, S. C.: Protein-calorie malnutrition in West Africa children. Rocky Mountain Med. J. 71:

403, 1974. 10.

11.

King, M., King, F., Morley, D., Burgess, L., and Burgess, A.: Nutrition for Developing Countries. Nairobi, Oxford, 1972. McKenzie-Pollock, J. S.: Putting health:

a ten

dollar health

a

plan.

price tag on Int. Dev. Rev.

1: 27, 1974. D.: Paediatric priorities in the developing world. London, Butterworths, 1973. 13. National Institute of Nutrition, Bogota, Columbia: A practical guide to combating malnutrition in the preschool child. New York, Appleton-CenturyCrofts, 1970. 14. Nchinda, T. C.: An integrated approach to the training of health personnel for developing countries : the Cameroon experiment. Tropical Doctor

12.

Morley,

15.

Taylor,

4: 41, 1974. C. E., and De Sweemer, C.: Nutrition and infection. In Food, Nutrition and Health. World Review of Nutrition and Dietetics. Basel, Karger, 1973.

The dilemmas of child health care in tropical Africa.

CHILD HEALTH The Dilemmas of Child Health Care in Tropical Africa Noel Guillozet, M.D., F.A.A.P.* IN MANY WAYS, the health problems of Cameroon typ...
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