Lecture delivered at the 80th Birthday Ceremony in   Honour of Prof. Oladipupo Hunponu-Wusu, MD, DFMC, FRCP, FFCM, DPH,FMCPH, FWACP, MRSH, MPS on June 17, 2014 by Prof. Akin Osibogun, MBBS (Lagos), MPH (Columbia), FMCPH, FWACP, FRSPH Chief Medical Director, Lagos University Teaching Hospital

Protocol

DISTINGUISHED ladies and gentlemen, it gives me a great pleasure to stand here today to give a lecture in honour of a great man who has been my teacher and mentor. Ten years ago I was privileged to be one of the speakers at his 70th birthday ceremony and today again he has requested me to be one of the main speakers at his 80th birthday ceremony. I am sure that I will play an even greater role at his 90th birthday ceremony by the grace of God.

   I crave your indulgence for the full disclosure of my affiliation with Professor Oladipupo Hunponu-Wusu. He was my teacher when I was in the medical school and when I returned from my postgraduate studies in the United States in 1986, he was kind enough to offer me a place in the Department as a Senior Resident Doctor. While in the department, my mentor ensured that he gave me responsibilities many thought were far above my level and the more I discharged those responsibilities, the more he gave me other ones. I only realized much later that his efforts were to prepare me for greater responsibilities and I remain most grateful.

  Perhaps I should give one or two examples of the uncommon exposures Professor Hunponu-Wusu afforded me. In 1987, the Lagos State Government assembled all the big Professors it could lay its hands on to develop a framework for the integrated development of the State’s rural areas and Professor Hunponu-Wusu was naturally one of the invitees. He gave me the invitation containing the topic assigned to him and asked me to research and come up with a draft which he vetted and corrected till we arrived at a final draft which then had both his name and mine. Two days to the workshop convened at the Administrative Staff College of Nigeria, my mentor directed that I would be the one to go and make the presentation.

  On getting to ASCON, I realized I was the small boy in the midst of several big professors and permanent secretaries. However, since my Professor had seen the paper I was going to present and since he had asked me to go there, I reassured myself and started my presentation with a shaky voice which became stronger as I realized everybody in the hall was interested in the points that were being presented. At the end of all the four or so papers presented in our session, I received more enquiries during question time than other presenters and during lunch participants were still showing interest in the points. You can only imagine what that experience did to my self-confidence. I can not thank my teacher enough for knowledge impacted and character moulded. Sir, may your shadow never dim!

  Now that you know that I can only be biased in pouring encomiums on Professor Hunponu-Wusu, I want to assure you that I am still a scientist and that as such, still work by verifiable facts. So all I will say about the celebrant will be facts which you can verify.

    Professor Oladipupo Hunponu-Wusu is a qualified Pharmacist, a Physician, a Public Health Specialist and a Professor. He is thus a man who has qualified in four principal areas – the 4 Ps. The Professor has contributed to the teaching and practice of Social Medicine, Public Health, Epidemiology and Primary Health Care for over four decades and his activities have spanned all  the six regions recognized by the World Health Organization –Africa, America, Asia, South East Asia/Australia, Europe and the Mediterranean. We can see that he has been a man in all the five continents!

   Because of his wide experience, his profound knowledge of his specialty, the depth of his analysis and the objectivity of his assessments, Professor Hunponu-Wusu has been a scholar who was much sought after by many Universities and Institutions of Higher Learning as an External Examiner, Guest Lecturer or Visiting Professor. He has been a teacher and external examiner to over 15 medical schools in West Africa. As Head of the Department of Community Health, College of Medicine, University of Lagos, he spearheaded the establishment of a Master of Public Health degree programme in 1980 and this was the first of such a programme in West Africa. From a modest intake of 6 students in 1980 the programme has grown in strength and has produced some 1000 MPH degree holders. 

  In simple economic terms, if we use the minimal cost of training a Nigerian for an MPH degree in the UK at 20,000 Sterling Pounds, we can estimate that the MPH Programme of the University of Lagos has directly saved some twenty Million Pounds or equivalent of N5 billion for the country. Other indirect benefit include the starting of another Master of Science degree in Public Health also in the department since 2005 and the starting of MPH degree programmes in several other Nigerian Universities. I am proud to have followed in the steps of the master by having the fortune of spearheading the establishment of the Master of Science in Public Health degree programme in that same department. Professoor Hunponu-Wusu is a trail blazer.

   It is indeed a privilege for me to have been invited to give a lecture at a ceremony such as this in honour of a man who is diligent in his work, a man who sits and dines with kings, a man born into a distinguished family and who chose to add further distinction to the family name; a man who enjoys his work as much as he enjoys his leisure; a man of importance locally and of great attraction internationally.  I am happy to be part of the various celebration activities rolled out to honour our own Professor Oladipupo Hunponu-Wusu.

Health Care Delivery: Where are we coming from? 

In the General African Studies course we took as Prelim Students at the University of Lagos in those days, we were taught about the start of human civilization in East Africa. Findings from the Olduvai Gorge would seem to have supported that theory. I have since built on that and other sources of history to come to some conclusions about what I believe has been the march of civilization. 

   From East Africa to the Middle East, then to Asia and then Europe, Civilization would seem to have progressed with every new civilization or empire building on the ruins of the old. From the Middle East some diffusion came back Southwards to West Africa and there are tribes in West Africa today with historical linkages to Sudan and the Middle East further North. There are even arguments that the Pharaohs in Egypt at some early points could have been blacks or dark-skinned persons. 

   There are stories of a very wealthy and influential woman who went all the way from West Africa to visit King Solomon in Israel. There is a tomb somewhere near Ijebu-Ode where this woman is said to be buried.   For me therefore, modern civilization, inclusive of modern medicine, is a testimony of our common humanity. Every region and every race has provided building blocks to the building of modern medicine. 

  Going through various literature and traveling to different parts of the World, it has become clear to me that all races and tribes have gone through similar historical pathways as far as medicine is concerned. Tribes and nations can still be found at different stations along that common path. From Folk medicine and the use of herbs; to the sin or supernatural theory of Diseases; to the crime theory of disease and now to modern theories of disease. 

   Herbs and concoctions for different ailments were discovered through trial and error methods. Unfortunately, in many societies information was passed down orally and many parts were lost. Nevertheless, folk medicine persists till today in many societies across the globe including in the most developed countries. 

  I have spoken about “Opa Ehin”, “Akape” and “Agbo Jedi” at another forum some five years ago. Even though attention was also drawn to the possible contributions of these unweighed and undosed remedies to increasing incidence of organ damage, I am not aware that we have done anything serious about them. They are still widely available at motor parks all over the place.

   The Supernatural or sin theory of disease presupposes that either a spirit must have escaped from the ill person or he must have been invaded by a malevolent spirit. Treatment therefore would appear to be straightforward. The demons or malevolent spirits must be cast out or the good spirit must be lured back into the patient’s body. 

   Casting out demons or promoting “deliverance” as forms of treatment for people who are not in states of physical, mental and social well-being is a thriving activity in many parts of Africa, Central America, South America and Asia today. This theory poses a great challenge to the delivery of modern healthcare services including protracted delays in access to modern health services. 

  We should note that the use of incantations, counter-spells, bloodletting, trephining, scarifications etc are continuing practices in many communities even in Nigeria with serious implications including loss of critical appropriate intervention time, introduction of agents of sepsis and outright haemorrhaging and death. From all accounts it would appear that the earliest medicine men were sorcerers, magicians and spiritualists with some of their descendants persisting till today. 

   In one community in Lagos – (Lagos of all places!) a man sustained a simple fracture of the tibia and a traditional bone setter quickly got hold of an unfortunate chicken whose leg was then broken and a splint applied just as splint was applied to the leg of the patient. An assurance was given that once the leg of the chicken healed, the leg of the patient would also heal. Six to eight weeks later, mission was accomplished. The patients’ fractured leg was apparently healed as he could now walk with it. 

  I was initially fascinated by the story above until I visited a colleague working at the National Orthopaedic Hospital in Lagos and he discussed with me the several cases of patients with compound fractures of the leg who had had the misfortune of being first treated by traditional bone setters. Many of the patients had had infection introduced with their compound fractures, resulting in osteomyelitis in many cases and septicaemia in some. In many of the cases where the bones had healed, there had been mal-alignment and shortening of the leg. I am sure you have your own stories. 

   That modern medicine is yet to totally displace incantations and the killing of cocks is a testimony of either its inability to be universally convincing or universally accessible- this is indeed a major limitation.

 The following warning was displayed somewhere in Britain to alert us that criminals sometimes operate. Our space is therefore also threatened by unqualified people who open shops and pretend to be doctors. That we have not adequately monitored our space and there is room for such charlatans and criminals is a major limitation. A colleague has suggested that for our environment, we should replace the “sometimes” with “often”, i.e “Criminals often Operate”!

  The Code of Hammurabi is one of the earliest writings available showing us how medicine was practiced in ancient Middle East. Hammurabi was a Babylonian King of the 18th Century BCE. This code included laws relating to the practice of medicine and the penalties for failure were severe:

   “If the doctor in opening an abscess shall kill the patient, his hands shall be cut off”. If however, the patient was a slave, the doctor was only obliged to supply another slave. 

  Levels of discrimination in access and quality of care persist even until today with obvious consequences for outcomes. The poor who are most at risk for several diseases are indeed most at risk of not getting access to needed health services. As I have often repeated to my postgraduate students, if a rich man and a poor man both contract tuberculosis, for example, the poor man would have died since 5 years ago while the rich man is still accessing the latest anti-tuberculous drugs.

  The poor man is at great pains to leave his place of employment or source of income to go in search of health care and will only do so when the condition has become unbearably complicated. And when he does approach the health service, he is constrained by limited personal and family resources and unable to get defining tests performed. Of what use is medicine that is not accessible? The outcomes for the poor are almost always predictable.

  The first physician to emerge in Egyptian history was Imhotep, Chief Minister to King Djoser in the 3rd Millennium BCE and who was regarded as the Egyptian god of medicine. Medicine at that time provided a list of remedies with appropriate spells and incantations. Although there was a widespread practice of embalming, this did not lead to any better understanding of anatomy.  It did however give us insights into the diseases suffered at that time including bladder stones, arthritis, tuberculosis of the bone etc. India, China and Japan also have a history of contributing blocks to the building of medicine.

   By 460 BCE, medical thought in Greece had advanced and many of the conceptions based on magic and religion were partially discarded.  Hippocrates, the man known as the father of medicine was born in the Island of Cos in this year.  The works attributed to him mark the stage in medicine where disease became regarded as natural rather than supernatural. Doctors were therefore encouraged to look for physical causes of illness.

  Hippocrates noted the effect of food, of occupation and especially of climate in causing disease, observations that are still quite valid today.  However, his greatest legacy would be the character of medical conduct embodied in the Hippocrates Oath.  This ethical code in one or other version has guided the practice of medicine for over 2000 years.

   With a population of about 120 million people, the country accounts for ¼ of the population of Africa and 47% of the population of West Africa.  The country’s landmass of 923,768m2 accounts for about 3% of the African continental mass and therefore has one of the highest population densities on the continent

   About 40% of the country’s population resides in urban areas with these areas growing at the rate of 4.8% annually.  The overall population growth rate for the countries is estimated at 2.8% annually. Providing health services to this large population is by itself, a major challenge.

The Nigerian people have always had access to some form of health services delivery by traditional healers and herbal practitioners in the different parts of the country.  However, what is now known as the orthodox/formal Nigerian health delivery system was first introduced as a service for the British Army detachment located in the country.

  With the integration of the British Army with the Colonial Government in Nigeria, the government gradually extended health services to the local people working in the civil service and their relatives and then to the local population living close to government stations.  One such health station which eventually became what is now known as the General Hospital, Lagos was established in 1893.

   Various religious bodies and private organization have also been very active in the evolution of health services in the country.  In fact the first true hospital in Nigeria was established about 1859 by the Reverend Father Coquard of the Catholic Church in Abeokuta and is known today as the Sacred Hearts Hospital. The establishment and growth of these various hospitals did not follow any explicitly formulated national health plans.

   The first attempt at national planning for the delivery of health services was the Walter-Harkness Ten year plan of 1946 which identified major health problems facing the country to include malaria and provided schemes and strategies to combat the problems.  The full implementation of this plan was aborted by the introduction of self government in some parts of the country from 1951. The different Regional Governments then instituted their different health plans to cover their respective areas of jurisdiction.

  From independence in 1960 health policies were enunciated either in the National Development plans or as government decisions on specific health problems.  The first two National Health Plans implemented between 1960 and 1974 concentrated on the provision of curative services. In the early 70’s, efforts were geared towards capital development such that about 76% of health budget was expended in this area. ( R.O. Olaniyan, Managing Health Development in Nigeria, Nig. J. of Health Planning and Management, Vol. 1, No 1, July-Dec 1995, pp 32-5).

   The 3rd National Development plan of 1975-80 for example attempted to deal with issues such as health manpower development and the provision of health facilities through the Basic Health Services Scheme. The Scheme aimed at the provision of health care infrastructure through the construction of Comprehensive Health Centres. The ambition was to increase the number of Comprehensive Health Centres from 250 to 1650 and the number of primary health clinics from 1600 to 7200 in five years. About 29% of the budget during this plan period was allocated to basic health and preventive services. Note must however be taken of the massive capital development planned in this subsector which was likely to reduce the proportion of operational funds. Nevertheless, this subsectoral allocation was a recognition of the importance of preventive services. 

   This period also witnessed the rapid expansion of the number of federally managed teaching hospitals for the training of different categories of health workers, particularly doctors, nurses, midwives and technicians. Schools of Health Technology were also established for the production of intermediate level manpower for community health. 

   The 4th Health Plan (1981-1985) identified the same health problems facing the population at the beginning of the 3rd health plan thus suggesting that most of the problems remained unresolved.

  The 5th National Development Plan 1987 – 1991 coincided with the period of the adoption of the primary health care strategy and the explicit formulation of a National Health Policy in 1988.  With effect from 1990 – 1992, the concept of 3-year National Rolling Plans was introduced. The vigorous pursuit of the primary health care strategy during this period led to gains in the health sector such as increased immunization coverage and the adoption of family planning methods.

   In 1995 a National Health Summit was held to review the National Health Policy and develop a plan for its implementation. The revised National Health Policy was published in 1996 and continued to recognize Primary Health care as the cornerstone of the National Health Care delivery system.

   The National Health Policy formulated in 1988 and reviewed in 1996 committed the three levels of government and the people of the country to intensive action to attain the goal of health for all citizens. Specifically, the goal was stated as the attainment of a level of health  that will permit all Nigerians to lead socially, and economically productive lives at the highest possible level. The implication of this policy declaration is the recognition of the need for action by all levels of government as well as by all Nigerians. 

   In allocating responsibilities, the National Health Policy puts the Local Government which is the closest administrative level to the people, as the implementing level for primary health care, while both the state and federal levels are expected to provide support both technically and financially. Furthermore, State Governments are expected to be responsible for secondary health care facilities while the Federal Government is expected to provide tertiary health facilities. All the levels of care are expected to be interlinked and constitute an integral part of a single health system.

   A recurring issue to which the policy attaches great importance is the need to provide appropriate mechanisms for involving the communities in the planning and implementation of services affecting their lives. Today, communities are only tokenly involved in the planning, implementation and evaluation of health programmes rather than as partners and stakeholders.

   Given the level of investments in health in the country as will be presented later, the health outcomes reported for the country are rather disappointing. With all the levels of government spending on the aggregate about 5% of the Federation Account on Health and thus meeting the WHO recommended minimum of 5%, it is obvious that there is a problem of inefficient use of resources. The key issue under this concern will therefore be to see how best more mileage can be extracted from existing levels of expenditure.

   A recognized threat to the health of the population is increasing incidence of poverty and worsening social conditions in the presence of a rapidly growing population.  The fall in living standards and the relative scarcity of resources have negatively impacted on the delivery of and access to health services by the people.  Using an index, Disability Adjusted Life Expectancy (DALE) that adjusts life expectancy for disability, the WHO ranked Nigeria in the 163rd position out of 191 countries. The DALE index attempts to capture population health in a broad way that takes account of the probability of survival as well as the quality of the survival. (World Health Report 2000: Improving Health Systems Performance WHO, Geneva)-

(World Health Report 2000: Improving Health Systems Performance WHO, Geneva)

Other health related data show that about 70% million Nigeria’s live below the poverty line. Poverty remains a single most important determinant of ill-health as it contributes significantly to increased exposure to disease-causing agent and also prevent access to health care services once disease has occurred.

Available data suggests that in general, the more the wealth of a country, the better the indices of health status of its citizenry. This fact then raises the concern for the linkages between poverty and ill-health and the need to alleviate poverty as a strategy for improved health. 

Table : Basic Economic and Health Indicators for Selected Countries, 1998

 Source: African Development Report 2000, African Development Bank