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Health services in Nigeria and the use of auxiliary personnel
HEALTH SERVICES IN NIGERIA AND THE USE OF AUXILIARY PERSONNEL* By W. N O R M A N - T A Y L O R , M.D.(LOND.),
t).P.t~.,
D.I.H.,
F.R.S.H.
(7he writer recently s:,c'nt tk:'ee yeatw & Nigeria as WHO Adrm.r o,~ Education and Training)
ON a population basis, Nigeria is by far the largest country in Afi'ica and i~ the 13th largest country in the world. At the 1953 census ~i~e populaticm was conservatively estimated at 30,000,000. By natural increase since that time it is now probably about 33,000,000--and still growing fast. There arc more people in Nigeria than in the whole of French West Africa from Dakar to Tehad. By comparison, Algeria has a population of" 10,000,000, Egypt 20,000,(X)0 mad the Belgian Congo, the largest geographical unit, t2,000,00t3. Although, with the rest of West Africa, Nigeria is the part of true Africa nearest to Europe, European influence has been relatively slight umil very recent times. This was due to its well-founded reputation as the "' White M,m~s Grave." It was the most recent of Britain's colonies, being tinall) annexed only in 1911. The country is now virtually independent and is divided into three autonomous states, or "Regions', as they are called, loosely knit into a federation with Lagos as the federal capital. The development of lhe country was slow until comparatively recently, when the effects of the emergence of an edt~cateci class began to show, especially in the south. Since then progress, economic and political has gone ahead in leaps and bounds. Government departments, which a few years ago migM have been run by one European, have blossomed into ministries employing hundreds of civil servants. The white administrators are disappearing fast but white business men and their African counterparts, are more and more in evidence. At the same time the corresponding appurtenances ofcivilisation are springing up everywhere: good hotel~, shops, roads, garages, hospitals. The cities are packed with traders, the streets swarm with hoofing taxis and buses, and overloaded lorries hurtle along well tarred main roads. 'The climate remains the same however. In the southern half of the country, it is hot and humid the whole year :round, sapping physical and mental enerD'. Africans apFarenfly suffer as much as Europeans in this respect. The climate has a similar devastating effect on inanimate objects: the process of rust and rot are acceiermed, rubber perishes quickly, cement loses its strength, the lenses of microsca}pes and cameras grow mouldy, delicate machinery ceases to function, paper and timbe~ get eaten by worms or ants, stored foods.get full o f weevil, bacterio*Tnc phrase tmxilmry. .~. e. .r s o ~ l l~ used nero i n the ,sen ~"- u:-~ by tt~ WHO, ~ e ~ y workers in a technical field with l ~ s than full profosSional training in that f/~3d~ 253
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7
logic=l :ulture media go mouldy and phoeographic film goes cloudy. That progress is being made so rapidly in spite of handicaps such as these does all the more credit of the people of this new Nigeria. EP1DEMIOLOGY
Nigeria is, or was until recently, a disease-ridden country. Its standards of hygiene about correspond to those of mediaeval Europe, and the corres;~onding diseases, smallpox, leprosy, typhus, are endemic. Tuberculosis and various forms of salmonella infection are extremely common. Devastating epidemics of cerebro-spinal fever occasionally hit the northern people during the dry season. One or other of the intestinal worms, hook, round or tape, are almost invariably found to be present in most stool specimens. Chotcra, fortunately, has never visited the country, and plague, though a few cases have occurred in Lagos, has never !aken hold. In addition to these "mediaeval" type diseases, the country has to contend with a climate that favours the life cycles of the more exclusively tropical parasites and insect vectors, where conventional "sanitation" as we know it is no protection. Malaria is by far the most important of the diseases under this heading. It is practically universal and anyone who has not an acquired immunity or is not taking artificial prophylactics would not remain unaffected for more than a few weeks. Yellow fever, if judged by serum immunity studies, is also almost universal; presumably it is in a mild form, though v~;~'ulent epidemics occur from time to time. FiIariasis, in ~;ts various forms, has high incidence in certain localities. The same applies to guinea-worm and bilharzia. Sleeping sickness and relapsing fever are scattered over the northern part of the country, while yaws is still widespread in the more backward parts of the south. As a background to all this, and contributing to the seriousness of the effects of the various afflictions, L. a state of widespread mahmtrition, particularly protein malnutrition. There areaiways kwashiorkor cases to be found in the children's wards of the hospitals, for example. In addition there still remains the " basic" pattern of ill-health that is not directly related to the social or geographical situation, the cardiacs, bronchitics, etc., the morbidity incidence that is much the same all the world over. The hospitals, of which there are about 200 of various sizes in the country, are always full to overflowing, and out-patient queues seem endless, but much of this is due to the scarcity of facilities and staff rather than to a high incidence of sickness. In the surgical wards there is a familiar sight--most of the beds are filled with the victims of road accidents. At the time of my visit, there were about 600 properly qualified medical practitioners in the whole country, of whom about 400 were in Government service including about 100 Europeans. The number of towns with'full specialist facilities is extremely few, perhaps seven or eight.
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SERVICES SANITARY
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STATE
Nearly all the towns, especially in the west and north are simply overgrown villages, built long before town planning was thought of. Unpaved lanes wind betwcen close-packed, mudwalled houses. Household waste-water runs oul through holes in the walls. Also conspicuous along the walls at the road side~. especially in the south, are the orifices of bucket latrines, as often as not ovcrttowing into the strect and surroundcd by chickens happily eating the fly maggots. Storm water drains, dangerously deep and presenting a formidable accident hazard to the unwary, line the major streets, and these usually contain stagnant water, foul and stinking with accumulated rubbish. Goats nuzzle in the litter for orange peel and the green leaves that serve as wrapping paper for food. The streets, especially the main ones, are crowded with pedestrians and pedlars, each contributing his quota to the rubbish. Shops, mostly open fronted, and small market stalls, line the main streets and seem stacked with goods spilling out over the drains and into the dusty roadway. There are no pavements or sidewalks, and very few streets are tarred, except in large towns like Lagos, Ibadan or Kano. There is no system of refuse collection as we know it, but each householder is supposed to take his rubbish to a "' b i n " ~ u s a a l l y a small brick-built chamber. There is one of these in each neighbourhood, and they are supposed to be periodically emptied by the authorities. In many towns I visited, emptyi~g seemed to have been forgotten and the "bins" stood as forlorn monuments amid growing mountains of rubbish. The rubbish is ultimately disposed of by tipping, but there is little attempt at control by covering with clean earth. Controlled tipping is of course often a counsel of perfection, even in the best run societies. In the smaller towns and villages there is usually a locally made incinerator, built of mud, shaped like a bee-hive. It is a pattern peculiar, 1 believe, to West Africa, but nevertheless cheap and el~ficient. Like everything else, however, the efficiency depends on the energy, and degree of supervision, of the labourer in charge. Latrines are usually the bucket variety in the south and shallow pits in the north, in both cases ~lmost always highly unsavoury. In the rural villages the " b u s h " serves this parpose. Nigerians are great ones at eating out and the wayside food peddlars do a stcady trade selling savoury tapioca or bean-cake by the leaf-full. Food hygiene is therefore extremely difficult. Meat is slaughtered on small concrete slaughter-slabs scattered through the towns. There is no pole or hoist and the carcasses are dressed and cut up on the floor amid their own blood and filth. Meat inspe,ztion is a routine but, judging by the books of returns, very little is ever condemned. Only in Lagos and Kano was anything like a proper abattoir to be seen. Water supplies are good for the most part, at least in the larger towns. It is greatly to the credit and foresight of the planners of former days--and
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many x~+aterworks date from the early twenties--that they gave priorily to this aspect of ~nitation. Undoubtedly this factor alone has been the salvation of towns where ahnost ever3' other sanitary tenet is ignored. In the smaller towns and villages the people still seem to prefer the local river or pond. Wells have bccn dug by the authorities in most villages but since the people have to provide their own r~pes and buckets (usually calabashes) the well water can never be .said to be hygieniczdly clean. It is, however, considered that something is accomplished, as well water is free from guinea-worm fleas. Housing is the biggest problem, and house inspection takes up most of the sanitary officials" time. Overcrowding and lack .of normal facilities are very common. Slum landlords are reaping the harvest of the present drift to the cities. No council houses have been built, or even contemplated, as far as I was able to discover. The public health inspectors, one would imagine, must have a hard time of it. It is difficult to see how the)' can even begin to do any work. One would expect them to develop neuroses like Pavlov's dogs, but they seem to go about their routine work contentedly enough in spite of getting little encouragement even from their own authorities, and making themselves thoroughly unpopular in the process. The inspectors have more power than their counterparts in the United Kingdom. They can take cases to court without reference to the council or even to their medical officers of health. In most cases there is no M.O.H. and the whole responsibility of the public health administration of quite larg~ ~,owns may rest on their shoulders. Full-time M.Os. H. in Nigeria can be counted on the fingers. They were to be found, at the time of my visit, only at Lagos, lbadan, Enugu, Port Harcourt, Kaduna and Kano. In other towns the local "'senior government medical officer" was usually e x o.[ficio M.O.H. regardless of whether he was specially qualified in the subject. RURAL IIEALTIt SERVICES In Nigeria, perhaps more so than in other parts of Africa, local authority government is well established and fairly well organised. Included in their powers is the provision of certain health facilities, with the capital expenditure subsidised from central funds. There seems to be little organised plan for rural health services but a distinct pattern has grown up over the years which fits pretty well into the modern concept of what is desirable. For the past 30 years or more, the local authorities have been providing their own "dispensaries," and sending one of their local lads to the government hospital to be trained as "'dispenser." The local authorities have to provide all medicines; the Government sends a rural medical officer periodically to deal with the sick who are beyond the powers of the dispenser. In recent years there has been a wide-spread d e m a n d f o r maternity hospitals, and these have sprung up in most villages. Local girls are sent to train as "Grade II midwives," and, on their return, they take charge of the
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maternity centrcs. There is no domiciliary midwifery, and the midwives have to do all the anle-natal and post-natal work, and advise on infant welfare. Alongside thcsc two services, though often with little or no co|anectior~, is the sanitary side of the triangle, with a local man in charge after a brief training as a "sanitary overseer". Owing to the sketchy nature of the training of these auxilizries, and to the fact that they are often l he onty interpreters of Western hea ith available to the local authorities, it is clear that very close supervision by propcrly qualified personnel is essential. The rural medical officer is supposed to exercise an overall supervision of these rural services, with particular supervision of the dispetlsary. In theory, for each medical division, there is also a "health sister", to supervise the midwives and infant w~!fare services. Until recently these were European women, and for the most part they have laid the foundation of a good service. The suw.rvisor of the sanitary overseers is the government "senior health inspector" of the medical division concerned, who usually has the R.S.H. local qualification. HFALTH
CENTRES
In cffect, therefore, a great many local government areas have their o,~n ~'hea~th centre", It is not necessarily all housed under one roof. and the re.speclivc health workers do not always have mu,~h to do with each other, but at least the pattern is there. Added to this may b e more specialised workers, e.g. leprosy assistants, yaws scouts, malaria oilers, and so on, who may or may not be in the employ of fhe central government. The tendency is for the larger local authorities to employ their own staff; for example in the larger towns they often employ health inspectors with R.S.H.-qualifications to supervise the overseers. The success or tailurc of the rural health service depends obviously on the degree of supervision that is exercised. For geographical reasons, supervision is often difficult, but one of the ctfief defects, in my view, was the fact that few supervisors seemed to understand the way to use auxiliary stall to understand their limitations, to understaz~d exactly what they can usefully be expected to do and not do. In other words the auxiliaries were not an integral part of a system, a cog in a machine~ but. in many cases, appeared to be expected to undertake full responsibilities and use an understanding of their subject which they clearly could not possess. This fault lay i n t h e system of training, by which supervisors were not trained in the ettieient use of auxiliaries, nor were the auxiliaries given proper understanding of their rble. Probably the reason for this was that the exact rble of these auxiliaries had never been clearly defined--there were no "'standing orders" laying down exactly what their duties were. The situation was being made worse by the habit o f posting to the rural areas, the newly arrived medical officers, fresh off the boat with the
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ink scarce dry on their British dcgrees. A more disturbing start to a medical career c~n hatdl S be imagined. To a visilor like myself, it was clear that lhe rural health system was not working. The dispensaries ~vcre not having much effect on the total load of sickness in their localities. In many places they were hardly patronised at all. The trcatmenl given often seemed to be archaic; for example, in the heart of Abada~ i found a dispen,,,ary that had not been visited by a medical officer for years, wherc the dispenser, equipped simply with carbolic and tow, was contentedly dabbing at children's tropical ulcers. The sanitary ovcrscers, similarly, seemc~2 to havc an impossible task and were clearly making iittle imprcssion. In m a @ places 1 saw pathetic attempls to build public latrines at the market place for example. Incinerators were often more successful and markcts wcrc usually well swept. In one place 1 was told the story of the sanitary oversecr, recently back from a refresher course, wl;o had ordered the flamboyant trees at the sides of the village street ....... planted by a long departed district commissioner--to be cut down, on the grounds that '" deforestation " preventcd sleeping sickness! The "'maternities" were perhaps more successful, and usually well patronised. TI~e chief criticism would be the over elaborate training and the inculcation of the " hospital" atmosphere towards normal confinements. I saw sphygmomanometers, complete with stethoscope, and pelvic calipers, which had clearly never been used nor likely to be. rile
TRAINING
OF
AUXILIARIES
The problem confl'onting thc advisers of the Government, which was already launched on programmes of accelcrated expansion in all fields, was the problem of providing increased medical and health facilities to keep pace with the increasing awareness and thc consequent increase in public demand. It has not been possible, in the space available, to describe the extent of lhc hospital and other medical facilities, suffice it to say that it was clear that any rapid improvemcnt in the total health situation could only be possible by increasing lhe number and efficiency of the auxiliaries. It is on the auxiliaries that the main bt,,rdcn of work must fall. It is they who are in direct contact witla (he bulk of the population. It is physically impossible for 500 or 600 doctors, to make much impression on 33,000,000 people, however well qualified they may be. They must delegate their duties, whether they be clinical, maternal or sanitaD'. Thc medical authorities at the time were only too well aware of the weaknesscs of the auxiliaries. Loud had been the denunciation o f the inefficiency and corruptness o f the dispensary attendants and sanitary overseers. It w a s clear that, if progress was to be made and maintained, a complete rethinking of the problem would have to be undertaken. It was at this point that the
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St RVICI~g
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World Heallh Organisafion was consuhcd, as a rcsolt c~f which l was asked to visit Nigcri:: ~nd make a report on lhc ',huation. This is not the p!acc 1~ di~cu,~ in dc~.a;l the recommendations that were cvcnttmlly made by WHO, but :~ fi:xv points may be m a d e Firstly. a~ indicated above, there ~::s clcarly a nccd to define much more exz~ctly the ptacc of the auxiliaries in thc overall plan. arid, ha~ing done so. lo make sure that all supervisors wcrc clearly aware of this. In this connection medical officcrs wcrc often as much to blame as anyone. The sccond important point was to devise a training policy and programme that would fit more cxactly with what was required of the trainees. The whole approach to training would have to be modificd and adapted to actual needs. Therc was a good dcal of confusion of thought on this point. In most cases the auxiliaries were ~ i n g given a watered-down version of the professional training, it being forgotten that without our basic educational background our usual synthetic approach was meaningless to them.. It is a common fault to assume that correct action will always follow if enough theory, is presented, but this is not the case. Training does not consisl of telling people what to do, but of producing people who will do what they know should be done. With auxiliary personnel, who have had little education except the ability to read and writc, the important thing is a precisc " j o b description" followed by demons|ralion and practice. Another mistake is to rely entirely on training "schools" to do the training, forgetting that, as in most walks of life, real proficiency comes from learning "'on the job". In this connection all supervising office~, whethcr medical, sanitary, or health sisters, should bear in mind their duty ofcontinuall.~ teaching and encouraging the auxiliaries who work under them. It was .'dso advised that the training methods used at the schools should be revised. Training is an art in itself and, just as a school teacher has to bc specially trained, so should an instructor in a training school, in the nursing profession this is well recognised, and sister tutors were to be found in Nigerk~, but lhis idea had not yet reached the training schools for auxiliaries. The WHO therefore felt it necessary to give detailed help and advice to the Governments concerning the training of instructors and the actual methodology of training. The selection of students and the methods of testing their obilities was also included under this heading. The W H O also suggested that training schools for the different aspects of rural health, dispensary, maternity and sanitary, might be brought under one roof so that the various categories of workers would more readily appreciate that they were all part of the same team, The Government of the Western Region put this suggestion into effect at once a n d set up their new Health Auxiliaries Training School at !badan, with a ~ i g r public health specialist as principal. Following this, the WHO was able to provide considerable assistance both in teaching personnel and equipment, in which I was privileged to take part.
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Finally it was suggested that all ranks of auxiliaries should be registered and that H:c Ministries of ttea!th should exercise a close control over all aspects of their recruitment, training, subsequent service and security of tenure. S U M M A R Y AND C O N C L U S I O N S A ~ery brief and incomplete survey of the present health problems in Nigeria has been given, with an outline of the steps being taken to deal wilh ~he siluation, Nigeria is, at 1he moment, a country which is developing at an increasingly accelerat ~g rate All the lbunda,tions have been laid, education, economic development, political maturity and heaP.h control, and now a great surge of progress :is taking place, A tremendously increasing demand for health services is naturally accompanying the country's awakening, It is equally clear that health services up to Western standards are not immediately possible, At present between 500 and 600 doctors are looking after the health of 33,000,000 people. The medical service as such cannot possibly expand rapidly enough. It follows thal the o~ty solution is to rely on the services of auxiliaries particularly i," the rural areas. For many years the rudiments of a ~aral health centpz system, with the three aspects, ciinical, maternal and sanitary has been evolving. It is this sen, ice which m~s~ be expanded and improved to meet the increasing health demands. The World Health Organisation was invited to advise on the re-organisafion of the an'angemenls for training all categories of health auxiliaries as an essential preliminary step. It is to be hoped that the way fins now been opened m ensure a greatly improved standard of service to the great mass of the people.
t).P.t~.,
D.I.H.,
F.R.S.H.
(7he writer recently s:,c'nt tk:'ee yeatw & Nigeria as WHO Adrm.r o,~ Education and Training)
ON a population basis, Nigeria is by far the largest country in Afi'ica and i~ the 13th largest country in the world. At the 1953 census ~i~e populaticm was conservatively estimated at 30,000,000. By natural increase since that time it is now probably about 33,000,000--and still growing fast. There arc more people in Nigeria than in the whole of French West Africa from Dakar to Tehad. By comparison, Algeria has a population of" 10,000,000, Egypt 20,000,(X)0 mad the Belgian Congo, the largest geographical unit, t2,000,00t3. Although, with the rest of West Africa, Nigeria is the part of true Africa nearest to Europe, European influence has been relatively slight umil very recent times. This was due to its well-founded reputation as the "' White M,m~s Grave." It was the most recent of Britain's colonies, being tinall) annexed only in 1911. The country is now virtually independent and is divided into three autonomous states, or "Regions', as they are called, loosely knit into a federation with Lagos as the federal capital. The development of lhe country was slow until comparatively recently, when the effects of the emergence of an edt~cateci class began to show, especially in the south. Since then progress, economic and political has gone ahead in leaps and bounds. Government departments, which a few years ago migM have been run by one European, have blossomed into ministries employing hundreds of civil servants. The white administrators are disappearing fast but white business men and their African counterparts, are more and more in evidence. At the same time the corresponding appurtenances ofcivilisation are springing up everywhere: good hotel~, shops, roads, garages, hospitals. The cities are packed with traders, the streets swarm with hoofing taxis and buses, and overloaded lorries hurtle along well tarred main roads. 'The climate remains the same however. In the southern half of the country, it is hot and humid the whole year :round, sapping physical and mental enerD'. Africans apFarenfly suffer as much as Europeans in this respect. The climate has a similar devastating effect on inanimate objects: the process of rust and rot are acceiermed, rubber perishes quickly, cement loses its strength, the lenses of microsca}pes and cameras grow mouldy, delicate machinery ceases to function, paper and timbe~ get eaten by worms or ants, stored foods.get full o f weevil, bacterio*Tnc phrase tmxilmry. .~. e. .r s o ~ l l~ used nero i n the ,sen ~"- u:-~ by tt~ WHO, ~ e ~ y workers in a technical field with l ~ s than full profosSional training in that f/~3d~ 253
254
PUIILIC
]HEALTH
VOL.
LXX1V
NO.
7
logic=l :ulture media go mouldy and phoeographic film goes cloudy. That progress is being made so rapidly in spite of handicaps such as these does all the more credit of the people of this new Nigeria. EP1DEMIOLOGY
Nigeria is, or was until recently, a disease-ridden country. Its standards of hygiene about correspond to those of mediaeval Europe, and the corres;~onding diseases, smallpox, leprosy, typhus, are endemic. Tuberculosis and various forms of salmonella infection are extremely common. Devastating epidemics of cerebro-spinal fever occasionally hit the northern people during the dry season. One or other of the intestinal worms, hook, round or tape, are almost invariably found to be present in most stool specimens. Chotcra, fortunately, has never visited the country, and plague, though a few cases have occurred in Lagos, has never !aken hold. In addition to these "mediaeval" type diseases, the country has to contend with a climate that favours the life cycles of the more exclusively tropical parasites and insect vectors, where conventional "sanitation" as we know it is no protection. Malaria is by far the most important of the diseases under this heading. It is practically universal and anyone who has not an acquired immunity or is not taking artificial prophylactics would not remain unaffected for more than a few weeks. Yellow fever, if judged by serum immunity studies, is also almost universal; presumably it is in a mild form, though v~;~'ulent epidemics occur from time to time. FiIariasis, in ~;ts various forms, has high incidence in certain localities. The same applies to guinea-worm and bilharzia. Sleeping sickness and relapsing fever are scattered over the northern part of the country, while yaws is still widespread in the more backward parts of the south. As a background to all this, and contributing to the seriousness of the effects of the various afflictions, L. a state of widespread mahmtrition, particularly protein malnutrition. There areaiways kwashiorkor cases to be found in the children's wards of the hospitals, for example. In addition there still remains the " basic" pattern of ill-health that is not directly related to the social or geographical situation, the cardiacs, bronchitics, etc., the morbidity incidence that is much the same all the world over. The hospitals, of which there are about 200 of various sizes in the country, are always full to overflowing, and out-patient queues seem endless, but much of this is due to the scarcity of facilities and staff rather than to a high incidence of sickness. In the surgical wards there is a familiar sight--most of the beds are filled with the victims of road accidents. At the time of my visit, there were about 600 properly qualified medical practitioners in the whole country, of whom about 400 were in Government service including about 100 Europeans. The number of towns with'full specialist facilities is extremely few, perhaps seven or eight.
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SERVICES SANITARY
IN
NIGERIA
255
STATE
Nearly all the towns, especially in the west and north are simply overgrown villages, built long before town planning was thought of. Unpaved lanes wind betwcen close-packed, mudwalled houses. Household waste-water runs oul through holes in the walls. Also conspicuous along the walls at the road side~. especially in the south, are the orifices of bucket latrines, as often as not ovcrttowing into the strect and surroundcd by chickens happily eating the fly maggots. Storm water drains, dangerously deep and presenting a formidable accident hazard to the unwary, line the major streets, and these usually contain stagnant water, foul and stinking with accumulated rubbish. Goats nuzzle in the litter for orange peel and the green leaves that serve as wrapping paper for food. The streets, especially the main ones, are crowded with pedestrians and pedlars, each contributing his quota to the rubbish. Shops, mostly open fronted, and small market stalls, line the main streets and seem stacked with goods spilling out over the drains and into the dusty roadway. There are no pavements or sidewalks, and very few streets are tarred, except in large towns like Lagos, Ibadan or Kano. There is no system of refuse collection as we know it, but each householder is supposed to take his rubbish to a "' b i n " ~ u s a a l l y a small brick-built chamber. There is one of these in each neighbourhood, and they are supposed to be periodically emptied by the authorities. In many towns I visited, emptyi~g seemed to have been forgotten and the "bins" stood as forlorn monuments amid growing mountains of rubbish. The rubbish is ultimately disposed of by tipping, but there is little attempt at control by covering with clean earth. Controlled tipping is of course often a counsel of perfection, even in the best run societies. In the smaller towns and villages there is usually a locally made incinerator, built of mud, shaped like a bee-hive. It is a pattern peculiar, 1 believe, to West Africa, but nevertheless cheap and el~ficient. Like everything else, however, the efficiency depends on the energy, and degree of supervision, of the labourer in charge. Latrines are usually the bucket variety in the south and shallow pits in the north, in both cases ~lmost always highly unsavoury. In the rural villages the " b u s h " serves this parpose. Nigerians are great ones at eating out and the wayside food peddlars do a stcady trade selling savoury tapioca or bean-cake by the leaf-full. Food hygiene is therefore extremely difficult. Meat is slaughtered on small concrete slaughter-slabs scattered through the towns. There is no pole or hoist and the carcasses are dressed and cut up on the floor amid their own blood and filth. Meat inspe,ztion is a routine but, judging by the books of returns, very little is ever condemned. Only in Lagos and Kano was anything like a proper abattoir to be seen. Water supplies are good for the most part, at least in the larger towns. It is greatly to the credit and foresight of the planners of former days--and
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LXXIV
NO.
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many x~+aterworks date from the early twenties--that they gave priorily to this aspect of ~nitation. Undoubtedly this factor alone has been the salvation of towns where ahnost ever3' other sanitary tenet is ignored. In the smaller towns and villages the people still seem to prefer the local river or pond. Wells have bccn dug by the authorities in most villages but since the people have to provide their own r~pes and buckets (usually calabashes) the well water can never be .said to be hygieniczdly clean. It is, however, considered that something is accomplished, as well water is free from guinea-worm fleas. Housing is the biggest problem, and house inspection takes up most of the sanitary officials" time. Overcrowding and lack .of normal facilities are very common. Slum landlords are reaping the harvest of the present drift to the cities. No council houses have been built, or even contemplated, as far as I was able to discover. The public health inspectors, one would imagine, must have a hard time of it. It is difficult to see how the)' can even begin to do any work. One would expect them to develop neuroses like Pavlov's dogs, but they seem to go about their routine work contentedly enough in spite of getting little encouragement even from their own authorities, and making themselves thoroughly unpopular in the process. The inspectors have more power than their counterparts in the United Kingdom. They can take cases to court without reference to the council or even to their medical officers of health. In most cases there is no M.O.H. and the whole responsibility of the public health administration of quite larg~ ~,owns may rest on their shoulders. Full-time M.Os. H. in Nigeria can be counted on the fingers. They were to be found, at the time of my visit, only at Lagos, lbadan, Enugu, Port Harcourt, Kaduna and Kano. In other towns the local "'senior government medical officer" was usually e x o.[ficio M.O.H. regardless of whether he was specially qualified in the subject. RURAL IIEALTIt SERVICES In Nigeria, perhaps more so than in other parts of Africa, local authority government is well established and fairly well organised. Included in their powers is the provision of certain health facilities, with the capital expenditure subsidised from central funds. There seems to be little organised plan for rural health services but a distinct pattern has grown up over the years which fits pretty well into the modern concept of what is desirable. For the past 30 years or more, the local authorities have been providing their own "dispensaries," and sending one of their local lads to the government hospital to be trained as "'dispenser." The local authorities have to provide all medicines; the Government sends a rural medical officer periodically to deal with the sick who are beyond the powers of the dispenser. In recent years there has been a wide-spread d e m a n d f o r maternity hospitals, and these have sprung up in most villages. Local girls are sent to train as "Grade II midwives," and, on their return, they take charge of the
I{EALTH
SERV1CE,q
IN
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maternity centrcs. There is no domiciliary midwifery, and the midwives have to do all the anle-natal and post-natal work, and advise on infant welfare. Alongside thcsc two services, though often with little or no co|anectior~, is the sanitary side of the triangle, with a local man in charge after a brief training as a "sanitary overseer". Owing to the sketchy nature of the training of these auxilizries, and to the fact that they are often l he onty interpreters of Western hea ith available to the local authorities, it is clear that very close supervision by propcrly qualified personnel is essential. The rural medical officer is supposed to exercise an overall supervision of these rural services, with particular supervision of the dispetlsary. In theory, for each medical division, there is also a "health sister", to supervise the midwives and infant w~!fare services. Until recently these were European women, and for the most part they have laid the foundation of a good service. The suw.rvisor of the sanitary overseers is the government "senior health inspector" of the medical division concerned, who usually has the R.S.H. local qualification. HFALTH
CENTRES
In cffect, therefore, a great many local government areas have their o,~n ~'hea~th centre", It is not necessarily all housed under one roof. and the re.speclivc health workers do not always have mu,~h to do with each other, but at least the pattern is there. Added to this may b e more specialised workers, e.g. leprosy assistants, yaws scouts, malaria oilers, and so on, who may or may not be in the employ of fhe central government. The tendency is for the larger local authorities to employ their own staff; for example in the larger towns they often employ health inspectors with R.S.H.-qualifications to supervise the overseers. The success or tailurc of the rural health service depends obviously on the degree of supervision that is exercised. For geographical reasons, supervision is often difficult, but one of the ctfief defects, in my view, was the fact that few supervisors seemed to understand the way to use auxiliary stall to understand their limitations, to understaz~d exactly what they can usefully be expected to do and not do. In other words the auxiliaries were not an integral part of a system, a cog in a machine~ but. in many cases, appeared to be expected to undertake full responsibilities and use an understanding of their subject which they clearly could not possess. This fault lay i n t h e system of training, by which supervisors were not trained in the ettieient use of auxiliaries, nor were the auxiliaries given proper understanding of their rble. Probably the reason for this was that the exact rble of these auxiliaries had never been clearly defined--there were no "'standing orders" laying down exactly what their duties were. The situation was being made worse by the habit o f posting to the rural areas, the newly arrived medical officers, fresh off the boat with the
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ink scarce dry on their British dcgrees. A more disturbing start to a medical career c~n hatdl S be imagined. To a visilor like myself, it was clear that lhe rural health system was not working. The dispensaries ~vcre not having much effect on the total load of sickness in their localities. In many places they were hardly patronised at all. The trcatmenl given often seemed to be archaic; for example, in the heart of Abada~ i found a dispen,,,ary that had not been visited by a medical officer for years, wherc the dispenser, equipped simply with carbolic and tow, was contentedly dabbing at children's tropical ulcers. The sanitary ovcrscers, similarly, seemc~2 to havc an impossible task and were clearly making iittle imprcssion. In m a @ places 1 saw pathetic attempls to build public latrines at the market place for example. Incinerators were often more successful and markcts wcrc usually well swept. In one place 1 was told the story of the sanitary oversecr, recently back from a refresher course, wl;o had ordered the flamboyant trees at the sides of the village street ....... planted by a long departed district commissioner--to be cut down, on the grounds that '" deforestation " preventcd sleeping sickness! The "'maternities" were perhaps more successful, and usually well patronised. TI~e chief criticism would be the over elaborate training and the inculcation of the " hospital" atmosphere towards normal confinements. I saw sphygmomanometers, complete with stethoscope, and pelvic calipers, which had clearly never been used nor likely to be. rile
TRAINING
OF
AUXILIARIES
The problem confl'onting thc advisers of the Government, which was already launched on programmes of accelcrated expansion in all fields, was the problem of providing increased medical and health facilities to keep pace with the increasing awareness and thc consequent increase in public demand. It has not been possible, in the space available, to describe the extent of lhc hospital and other medical facilities, suffice it to say that it was clear that any rapid improvemcnt in the total health situation could only be possible by increasing lhe number and efficiency of the auxiliaries. It is on the auxiliaries that the main bt,,rdcn of work must fall. It is they who are in direct contact witla (he bulk of the population. It is physically impossible for 500 or 600 doctors, to make much impression on 33,000,000 people, however well qualified they may be. They must delegate their duties, whether they be clinical, maternal or sanitaD'. Thc medical authorities at the time were only too well aware of the weaknesscs of the auxiliaries. Loud had been the denunciation o f the inefficiency and corruptness o f the dispensary attendants and sanitary overseers. It w a s clear that, if progress was to be made and maintained, a complete rethinking of the problem would have to be undertaken. It was at this point that the
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World Heallh Organisafion was consuhcd, as a rcsolt c~f which l was asked to visit Nigcri:: ~nd make a report on lhc ',huation. This is not the p!acc 1~ di~cu,~ in dc~.a;l the recommendations that were cvcnttmlly made by WHO, but :~ fi:xv points may be m a d e Firstly. a~ indicated above, there ~::s clcarly a nccd to define much more exz~ctly the ptacc of the auxiliaries in thc overall plan. arid, ha~ing done so. lo make sure that all supervisors wcrc clearly aware of this. In this connection medical officcrs wcrc often as much to blame as anyone. The sccond important point was to devise a training policy and programme that would fit more cxactly with what was required of the trainees. The whole approach to training would have to be modificd and adapted to actual needs. Therc was a good dcal of confusion of thought on this point. In most cases the auxiliaries were ~ i n g given a watered-down version of the professional training, it being forgotten that without our basic educational background our usual synthetic approach was meaningless to them.. It is a common fault to assume that correct action will always follow if enough theory, is presented, but this is not the case. Training does not consisl of telling people what to do, but of producing people who will do what they know should be done. With auxiliary personnel, who have had little education except the ability to read and writc, the important thing is a precisc " j o b description" followed by demons|ralion and practice. Another mistake is to rely entirely on training "schools" to do the training, forgetting that, as in most walks of life, real proficiency comes from learning "'on the job". In this connection all supervising office~, whethcr medical, sanitary, or health sisters, should bear in mind their duty ofcontinuall.~ teaching and encouraging the auxiliaries who work under them. It was .'dso advised that the training methods used at the schools should be revised. Training is an art in itself and, just as a school teacher has to bc specially trained, so should an instructor in a training school, in the nursing profession this is well recognised, and sister tutors were to be found in Nigerk~, but lhis idea had not yet reached the training schools for auxiliaries. The WHO therefore felt it necessary to give detailed help and advice to the Governments concerning the training of instructors and the actual methodology of training. The selection of students and the methods of testing their obilities was also included under this heading. The W H O also suggested that training schools for the different aspects of rural health, dispensary, maternity and sanitary, might be brought under one roof so that the various categories of workers would more readily appreciate that they were all part of the same team, The Government of the Western Region put this suggestion into effect at once a n d set up their new Health Auxiliaries Training School at !badan, with a ~ i g r public health specialist as principal. Following this, the WHO was able to provide considerable assistance both in teaching personnel and equipment, in which I was privileged to take part.
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PUBI_IC IlI:!AI. TH 'VOL t_XXIV NO. 7
Finally it was suggested that all ranks of auxiliaries should be registered and that H:c Ministries of ttea!th should exercise a close control over all aspects of their recruitment, training, subsequent service and security of tenure. S U M M A R Y AND C O N C L U S I O N S A ~ery brief and incomplete survey of the present health problems in Nigeria has been given, with an outline of the steps being taken to deal wilh ~he siluation, Nigeria is, at 1he moment, a country which is developing at an increasingly accelerat ~g rate All the lbunda,tions have been laid, education, economic development, political maturity and heaP.h control, and now a great surge of progress :is taking place, A tremendously increasing demand for health services is naturally accompanying the country's awakening, It is equally clear that health services up to Western standards are not immediately possible, At present between 500 and 600 doctors are looking after the health of 33,000,000 people. The medical service as such cannot possibly expand rapidly enough. It follows thal the o~ty solution is to rely on the services of auxiliaries particularly i," the rural areas. For many years the rudiments of a ~aral health centpz system, with the three aspects, ciinical, maternal and sanitary has been evolving. It is this sen, ice which m~s~ be expanded and improved to meet the increasing health demands. The World Health Organisation was invited to advise on the re-organisafion of the an'angemenls for training all categories of health auxiliaries as an essential preliminary step. It is to be hoped that the way fins now been opened m ensure a greatly improved standard of service to the great mass of the people.