Dear Colleagues (and especially those from Nigeria!),

 

Could I respectfully call your attention to the annual UNICEF collection of data entitled The State of the World's Children ? Difficult questions can some times be resolved by studying the facts. Designing health services to fit the needs of those most at risk (and those most vital to any nation's future), namely, the mothers and children, requires addressing their mortality statistics.

 

In the case of Nigeria, the MCH needs are dire:

 

According to UNICEF, the Nigerian "MMR" or Maternal Mortality Ratio in 2008 was 840 ,compared to 350 in Ghana, 24 in the USA, 7 in Norway and 590 for the aggregated "least developed nations". As to 0-5 Child Mortality (per 1000 live births), in 2009, Nigeria's was 138/1000 LBs, compared to 69 in Ghana, 8 in the USA, 3 in Norway and 121 in the aggregated "least developed nations".

 

The relative numbers of doctors (most expensive), midwives, nurses, public health officers, pharmacists, lab & other specialty workers, and community health workers (least costly), has be determined by what each society (or community) can afford...except in dictatorships (Cuba or China for example) where the government can force anyone to go anywhere and be paid whatever the state wants to pay them!

 

The USA, which (as indicated by the above data) has by no means the best healthcare, can afford lots of doctors,  just as we think we can afford lots of big hospitals (very very expensive) and a totally inadequate primary care system. (And by the way, Professor Ana, we don't represent the "white world"....over half of our population and our President being brown!), But in any case, we aren't a model of how things should be! Our doctor based system is hugely overpriced and many of our mothers and children are under served!.But at least we have the money to pay for it.

 

When Professor Ransome Kuti was working at the World Bank, he had a chance to study health care around the world, and when he returned to Nigeria it was with a renewed dedication to help build an adequate primary care system as the foundation for better health for his people. He understood that without a solid foundation of primary maternal and child care to keep most mothers and children well and out of the need for hospital care, there would never be enough beds within their geographic and monetary capacities to meet their needs.

 

Unfortunately, other Nigerian doctors (except for a few like Dr Oluyumbo!), failed to understand his vision and instead of providing leadership by supporting primary care (much of which is routineizable and fully within the scope of non-doctors), while concentrating their expertise on the provision of excellent secondary and tertiary (specialist) care, chose to view his concepts as some kind of colonialist trick to consign the population to permanent second class care! (Many US doctors have been comparably short sighted in opposing midwives and nurse practitioners, despite their excellent education and the preponderant evidence of the excellence of the care they provide!)

 

When Nigeria is able to bring its maternal and 0-5 mortality rates down to reasonable levels it can perhaps afford hugely expensive speciality hospitals and doctors, but only solid primary care for all families everywhere will solve the dire death rates that prevail. And since so few doctors are motivated to build primary care for all, it will have to be up to the people, working through their local authorities to do it. And when they've built it and paid for it, they'll fight for it.

 

Unfortunately, no amount of antibiotics, MRI's and other diagnostic equipment, specialty operations, cancer treatment, life- and quality of life- saving as they are, will bring mother/child death rates down to reasonable levels, any time soon. Nor will weak governments awash in mineral wealth do this.

 

Only a quality primary care system addresses the causes of mortality: safe delivery, women's education and empowerment, day to day basic curative care, exclusive breast feeding, adequate weaning foods and family nutrition, growth monitoring (to detect malnutrition before it becomes marasmus, kwashiorkor or obesity), modern contraception, wider birth intervals, immunizations, accident and substance abuse prevention, basic hygiene, healthy parenting & healthy living. Only when these are all addressed, will mortality decline, after which hospitalization becomes the exception, and doctors can get on with treating what is not preventable.

 

The best way to honour that exceptional Nigerian physician, Olikoye Ransome Kuti, is to follow in his very large footsteps towards a more rational, far more cost effective, and far more humane health care system !

 

Respectfully,

Nicholas Cunningham MD Dr P.H.

HIFA2015