Augustine Amangeh, Chaplain, The Village Retirement Community
Nigeria is a country that lacks sufficient medical facilities to meet the needs of the population. Most people rely on folk medicine and dibias when they are ill. There are many reasons for this, including the expense, scarcity of medical facilities, fear of modern medicine, and acceptance of traditional beliefs and practices. In response to the needs of the people of my village I was able to help start a children’s hospital which has now been expanded to serve the health care needs of all the people.
In his article, “Distrust, Social Justice and Healthcare,” Dr. Howard McGary copiously quotes from A Theory of Justice (Rawls, 1971, p. 90-95) and Political Liberalism (Rawls, 1993, p. 1). Rawls strongly believes that food, healthcare, and housing are “primary goods” (Rawls, 1971, p. 76-80) and defines primary goods as things that every rational person is presumed to want (Rawls, 1971, p. 76-80).
Food, healthcare, and housing are basic to every rational person irrespective of his or her status in life. The allocation of these goods is subject to the constraints of justice, and processing these goods has a bearing on a rational person’s self-concept. The cornerstone of Rawls’s account of social justice is his belief that the least-advantaged members of society, as measured by their possession of the primary goods, should be the gauge by which we judge the justness of the basic structure of society (Rawls, 1971, p. 76-80). Pope Pius XII, in his Pentecost Sunday radio message on June 1, 1941, said: “Material goods have been created by God to meet the needs of all men, and must be at the disposal of all of them. Every man indeed as a reason-gifted being has, from nature, the fundamental right to make use of the material goods of the earth.” In May 1966, Pope Paul VI reiterated almost the very words of Pius XII: “The goods and fruits of this world were created for all. No one has a right to reserve them for themselves, neither individuals nor communities. All have the grave duty to place them at the service of all people.” Pius XII went on to warn that even in the midst of surplus production and plenty, some people may be left out if there is no just and equitable distribution of goods.
Both the nation’s economy and its abundance should be directed to ... the personal development of every individual.
If such a just distribution of goods were not to be effected or just imperfectly ensured, the true end of the national economy would not be achieved, opulent though the abundance of available goods might be, since the people would not be rich, but poor, as they would not be invited to share in that abundance.
Both the nation’s economy and its abundance should be directed to achieve one purpose, and this is the personal development of every individual. Pius XII was again right when he said
The economic wealth of a nation does not properly consist in the abundance of goods judged by a sheer material computation of their worth, but it consists in what such an abundance does really and effectively mean and provide as a sufficient material basis for a fair personal development of its members.
Paul VI expressed a similar opinion when he said
It is not only about reducing the impressive inequality that puts 15 per cent of humanity in possession of 85 per cent of world production. It is about implementing technical and economic development, but promoting an integral and harmonious development of the human person; allowing each one to lead an existence in keeping with its dignity of a being created in the image of God.
Nigeria is a different “animal” altogether from most other countries. In most parts of Nigeria there are no primary goods to talk about. Social justice itself can be heard mentioned occasionally from the pulpits but rarely from the government. “During the colonial period, different ecclesial agencies supported the idea of healthcare delivery, alongside their other efforts at evangelization” (Agbali). Qualified medical doctors and nurses are few, and badly needed drugs are scarce and expensive. “Healthcare centers are often shacks or huts. In many places the Nigerian public healthcare delivery is in shambles, and hospitals and clinics are ghost centers of an effective healthcare delivery system” (Agbali). We know that even where healthcare is available, social inequalities may pose another hindrance to its accessibility. Since justice is considered to be the first virtue of social institutions, injustice demands action. The action demanded can, and often does involve state intervention (McGary, 1999, p. 1). But where both the state and local government organizations are incapable of providing any meaningful assistance, adults, pregnant women, and children die of common communicable but curable endemic diseases. This is the typical case in most parts of Nigeria. Still Article 25 of the Universal Declaration of Human Rights (1948), states,
"Malaria ... is still a big menace in Nigeria."
Everyone has the right to a standard of living adequate for the health and well-being of himself and his family including food, clothing, housing, medical care and necessary social services. In 1966 the UN adopted the International Covenant on Economic Social and Cultural Rights (ICESCR), which Nigeria ratified in 1994.
Malaria, for example, is still a big menace in Nigeria. Before the civil war in Nigeria, malaria accounted for about 40% of children’s deaths in Nigeria, especially in the Mbaise region. In the latest update on his article, “Preventing Childhood Malaria Deaths in Mashegu,” Dr. Chukwumuanya Igbokwe states
During the period from Early April to Mid May (2008), PSJ’s Malaria project team comprising a primary care physician, a community health nurse and two community health extension workers conducted malaria control outreach activities in five rural communities ….The mobile team also treated 321 cases of malaria in children and administered antimalarial chemo-prophylaxis to 71 pregnant women (Igbokwe, 2003, p.3).
"Wellness and well-being should be the end result of every healthcare system."
In Nigeria today, the missionaries and, in a very special way the Catholic Church, try to deliver a holistic healthcare system for the benefit of all. They believe that the idea of healthcare and well-being are inseparable. Wellness and well-being should be the end result of every healthcare system. While they tried to set up such a holistic healthcare system, they had to fight other social anomalies in Nigeria. Some of these anomalies include socio-economic inequities in healthcare seeking, indigence and limited access to healthcare, fear and distrust in seeking modern healthcare, and people’s imbedded trust in traditional herbal medicine.
In general, the economic system in Nigeria encourages the rich to grow richer and the poor to get poorer. Nigeria is not alone in an economic quagmire such as this. The “haves” in Nigeria send their sick family members to countries like Britain, Germany and the United States for treatment. Meanwhile the “have-nots” depend on the local government healthcare centers for whatever treatment they can get. Dorothy N. Ucheaga puts it this way
The political economy promotes inequality and even when it appears that efforts are made to implement social justice, what actually obtains in practice is that a few individuals are enriched while the majority is deprived. And because of the outflow of the resources perpetuated by the few, there have not been ample resources to go round. So the implementation of social justice has been fraught with certain discriminatory policies culminating in its politicization and commercialization (Ucheaga, 2001).
Hyacinth E. Ichoku of the University of Nigeria-Nsukka said
In many developing countries there are widening inequalities between the subsistent poor and the affluent rich. In the past one and a half decades, rising inequality between the rich and the poor in Nigeria has become a major source of national and international concern (Ichoku, 2003).
These inequalities represent an obvious violation of distributive justice.
"Politics is another big factor that helps to create social inequality in Nigeria."
Politics is another big factor that helps to create social inequality in Nigeria. As soon as one finds oneself in any political position, he or she tries to accumulate much or all of the public funds for personal use.
Politics even under democratic governments became fundamentally the struggle for the control of the enormous resources concentrated at the center and often used for the patronage by the government in power. Government increasingly became, “a magnet for all facets of political and economic life, consuming the attention of traders, contractors, builders, farmers, traditional rulers, teachers, as much as that of politicians or politically motivated individuals (Ayogu, 1999. p.170). Access to state resources or being ‘politically connected’, therefore, became a major determinant of income and wealth distribution in Nigeria. Those with access to state power corruptly enriched themselves …” (Ichoku, 2003).
It was not until my freshman year in high school that I went to a hospital for the first time. The school made it possible for me to go when I strained my ankle while playing soccer. My parents usually treated me at home because they could not afford any hospital bill. This is still true for thousands of families in Nigeria today. For example, I visited Nigeria in January 2008. One day, I returned very late from a visit and I was told that a certain woman had waited for me all day and had just left. She came from the nearby village’s children’s hospital to seek financial help for her 15-year-old daughter who had an appendectomy at the hospital. My sister- in-law insisted on my going there immediately because she said the woman was crying so. My younger brother drove me to the hospital and I met the woman. She told me that she hardly makes 100 Naira or one dollar a day, and the bill she received for her daughter’s operation was 33,000 Naira, or about $300. Her daughter, who could not walk upright because of the surgery, stood beside her mother as she talked to me. I asked her what would happen if the bill was not paid. She said that since her family had no piece of land to sell, she would beg the hospital to see if they could let her work for them for free instead of paying the bill. I told her to take her daughter home whenever she was discharged and not to worry about the bill. The daughter started crying and her mother joined her, tears of joy I guess, and together they gave me a big hug.
"My parents usually treated me at home because they could not afford any hospital bill."
The University of Pennsylvania African Studies Center said this about Nigeria
In this country which God has endowed with an abundance of human resources, Nigerians are faced with starvation and destitution of incredible magnitude. Workers do not earn enough to live above starvation level; one can imagine the deplorable conditions of the teeming population of the unemployed … Greed, corruption, sectionalism, gross abuse of human rights and militarization of the Nigerian psyche continues unabated ... Unfortunately, the oil money in Nigeria is in pockets of very few, while the majority of the populace is poor. Nigeria is a rich country in which 75% are poor while the top 1% usually those with strong links to the corridors of power rival the affluence anywhere in the world. Income disparity between the top 1% and the bottom 75% in Nigeria is the worst in the world (Robinson, 1997, p. 1).
It is generally believed that every healthcare system should be concerned about the medical needs of the whole community and its aim should be the treatment of every patient. This happens often where both the doctors and every other medical staff put their patients first before any other thing. Sadly enough, this does not happen in most Nigerian hospitals. In what is called a general hospital, that is state-run hospitals, you bring your own supplies to the hospital. This includes food, water, syringes, and bandages. The doctor tells patients where to buy the medical supplies, usually his own pharmacy nearby. A deposit, which must be paid before a doctor touches a patient, is half the bill which has been decided by the doctor. Should it be necessary to go to the emergency room the minimum wait is 12 hours. The mistreatment and malpractice of doctors leave one dumbfounded, though I suppose this happens in other parts of the world as well.
"In ... a general hospital ... you bring your own supplies to the hospital."
I believe it is a moral duty to treat patients well. “Do unto others as you would like them do unto you” (Holy Bible, King James ver.). Immanuel Kant even warned against the mistreatment of animals because that might affect our treatment of human beings. Kant claims that we have duties not to be cruel to animals because this type of cruelty will determine the genuine duties we have to persons. Although treating animals cruelly does not violate Kant’s categorical imperative, such treatment damages our benevolent feelings and makes us prone to be cruel to people as well. (Kant, 1963) The key phrase in this last statement is benevolent feelings and many caregivers do not have this, especially in Nigeria.
I witnessed this first-hand in 2000. A young lady was in a car accident and I was asked to visit her at the hospital. She had a broken ankle and other bodily injuries. First I ministered to her and then talked to her orthopedic doctor who assured me that her ankle would be fixed. Every two weeks he would ask for more money but refused to listen to the patient’s complaints because he claimed to be the only bone expert in the city. The patient ended up with a fused ankle and could not walk without crutches. She was sent to a hospital in another city where her ankle was fixed correctly. Later, she married happily and now has two beautiful daughters.
The Tuskegee syphilis experiment here in the United States is one of the many examples of how caregivers can be callous at times.
In the 40-year Tuskegee Study, there were 399 black men with syphilis and 201 controls. The unwitting participants were not exposed to syphilis by the researchers, but they were not treated for it either. Even after the discovery of penicillin, the syphilitic men in the study were not informed about their condition, nor were they treated (Jones, 1993).
"The traditional herbalist in my community is called “Dibia.”"
Such non-benevolent behavior on the part of caregivers plants the seed of distrust in the minds of the community, especially the sick.
Earlier I mentioned that the first time I went to a hospital was my junior year in high school. Before then, my parents, especially my mother, used herbal medicine whenever I was injured or sick. She showed me every leaf and herb that could cure disease and promote healing. They worked on me. For example, the best chewing stick, which is better than a tooth brush and paste, is right behind my backyard here in the United States. Don’t ask me the name because I do not know. But I know what it does. The traditional herbalist in my community is called “Dibia.” He or she can cure anything from a common cold to diabetes. However, this is only a claim but many people believe in dibias. Recently, some of them have claimed to have a cure for HIV. Still many people are suffering from this disease. The only thing they do not do is perform surgery, but they can be called upon to open up a dead person’s body to look for the cause of death and remove it before burial. They can also fix broken bones. Reportedly, there was a case where someone had been to an orthopedic hospital for a broken bone and when the person returned, the broken bone was still crooked. The person was then sent to a dibia who broke the limb again and started afresh. In most cases, they do a better job than the orthopedic hospitals. However, some patients have died of serious infections. One of the dangers with herbal medicines is that there is no stipulated dosage.
When it comes to using the available primary health care centers, many people first go to the dibia. According to one study,
Principal components analysis was used to create a socio-economic status (SES) index, which was divided into quartiles … Logistic analysis was used to examine the determinants of use of PHC centers. The poorest quartile was more likely to use low-level providers (patent medicine dealers, shops, herbalists) and least likely to use the PHC centers (Onwujekwe, 2005, p. 455).
"...many people first go to the dibia."
The patent medicine shops with their often self-trained and self-employed pharmacists offer the people a cheaper alternative to health care centers.
Other important segments of the health care market are the pharmacy shops, the patent medicine shops and the traditional health care providers. Until recently, these health care providers were largely unregulated and mushroomed in every nook and corner of even the remotest villages. New regulations have not outlawed their existence, particularly the patent medicine stores and the traditional practitioners but only prohibited them from selling certain categories of drugs over the counter. They still remain the first port of call for most Nigerians who are poor and unable to afford formal health care from the more established practitioners (Ickoku, 2003).
Reducing income inequalities, unfair distribution of resources, distrust in the existing health care system, and a deep trust in the traditional medicine providers (dibias): these were the health demons the missionaries had to fight against in order to establish a worthwhile health care system for the communities. In the Nigerian health care system and community, the traditional health care providers are there to stay. Yet, they can often lead to tragedy.
"The fear factor comes from uneducated parents who are still skeptical about scientific medicines."
A 19-year old Polytechnic female student becomes pregnant following sexual indiscretion with a married schoolteacher. She is petrified of the consequences and seeks the aid of a traditional abortionist in the backwoods of a city center. A week later she is brought into the hospital with roaring septicemia from pelvic infection. She rapidly passes from anuria to delirium to convulsions and eventually succumbs (Orabuchi, 2005, p. 2).
The fear factor comes from uneducated parents who are still skeptical about scientific medicines. Such parents sometimes believe that any type of medicine will eventually harm their children, or may even affect their sexuality or gender. This false assertion becomes more serious when such parents are joined by influential persons in the community. For example
In 2003, after religious and political leaders in the Kano region banned polio immunization, contending that it sterilized girls and spread HIV, an outbreak of polio spread through Nigeria and into neighboring countries the following year. The Kano region lifted its ten-month ban against vaccination in July 2004. On Aug. 24, there were 602 polio cases worldwide, 79% of which were in Nigeria (Orabuchi, 2005, p. 2).
"...Roman Catholic missionaries established their first hospital at Abeokuta, Nigeria, around 1860."
Having dealt with some of the community’s social justice issues, Roman Catholic missionaries established their first hospital at Abeokuta, Nigeria, around 1860.
Western medicine was not formally introduced into Nigeria until the 1860s, when the Sacred Heart Hospital was established by Roman Catholic missionaries in Abeokuta. Throughout the ensuing colonial period, the religious missions played a major role in the supply of modern health care facilities in Nigeria. The Roman Catholic missions predominated, accounting for about 40 percent of the total number of mission-based hospital beds by 1960. By that time, mission hospitals somewhat exceeded government hospitals in number: 118 mission hospitals, compared with 101 government hospitals (Metz, 1991, p. 1).
Later the Sudan United and Sudan Interior Missions also established hospitals. These hospitals played very important roles in the training and education of hospital staff including nurses, paramedical personnel and doctors. “In addition, the general education provided by the missions for many Nigerians helped to lay the groundwork for a wider distribution and acceptance of modern medical care” (Metz, 1991, p. 1).
Social Justice and the Treatment of HIV/AIDS in Nigeria
This paper would be incomplete if nothing is said about the HIV/AIDS epidemic in Africa, Nigeria included. I quote from recent newspapers and research headlines:
Nigeria: New study reveals discrimination by health professionals against people living with HIV/AIDS fueled by fear of infection, lack of protective supplies.
"This paper would be incomplete if nothing is said about the HIV/AIDS epidemic in Africa, Nigeria included."
The health sector is not immune to the kind of virlent discrimination that has hurt people with HIV/AIDS for many years. It is a very serious impediment to adequate AIDS treatment and affects the willingness of people with HIV to come forward.
In the last few years, Nigeria has been in the news in relation to claims of discrimination against people living with HIV/AIDS. Curiously and quite sadly, the discrimination has been in the hands of health professionals … A confrontation with ethical questions and issues of discrimination in the context of HIV/AIDS engenders questions bordering on social and natural justice; any discussion of peoples and situations in this framework cannot be easy.
People living with HIV/AIDS (PLWA) face many forms of stigma and discrimination… In addition to experiencing unfair treatment in their families, communities, and places of work, PLWA may encounter discrimination from health-care professionals. This can interfere with effective prevention and treatment. Discriminatory practices in the health-care sector may also appear to legitimize other forms of discrimination against PLWA.
"AIDS was officially found in Nigeria in 1987."
HIV-related stigma and discrimination remains an enormous barrier towards effectively containing the spread and prevention of the epidemic. We observe that the Constitution of the Federal Republic of Nigeria guarantees fundamental human rights … However; there is currently no specific legislation on HIV/AIDS. Human Rights violations are widespread, ranging from common place non-consensual HIV testing to the arrest and containment of all AIDS patients by the military administrator of a state ...
AIDS was officially found in Nigeria in 1987. This means that it must have existed before this time. The Joint United Nations Programme on HIV/AIDS (UNAIDS) intervened, and they provide some very important statistics.
UNAIDS estimates that in Nigeria, around 3.1 percent of adults between ages 15-49 are living with HIV/AIDS … by the end of 2007, there were an estimated 2,600,000 people infected with HIV. Approximately 170,000 people died from AIDS in 2007 alone. In 1991 the average life expectancy was 53.8 years for women and 52.6 years for men. By 2007 these figures had fallen to 46 for women and 47 for men.
The Nigerian government is not doing enough to combat this epidemic, which is in no hurry to leave Africa. Nigeria established the National Action Committee on Aids (NACA) and the HIV/AIDS Emergency Action Plan (HEAP).
Despite these positive intentions for tackling the epidemic, in 2006 it was estimated that just 10% of HIV-infected women and men were receiving antiretroviral therapy and only 7% of pregnant women were receiving treatment to reduce the risk of mother-to-child transmission on HIV.
Treatment and drug supplies are in short supply or are non-existent in many remote areas of Nigeria.
When antiretroviral drugs (ARVs) were introduced in Nigeria in the early 1990s, they were only available to those who paid for them. As the cost of the drug was very high at that time and the overwhelming majority of Nigerians were living on less than $2 a day, only the wealthy minority were able to afford the treatment.
"...people all over the world are coming to the aid of Nigeria."
All hope is not lost, however. The future may hold a better prospect for people with HIV/AIDS in Nigeria, because people all over the world are coming to the aid of Nigeria.
With the large amount of money being donated from international funds and a government dedicated to increasing preventive measures and treatment access, some are feeling slightly more optimistic about the future of HIV/AIDS in Nigeria. However, it remains to be seen whether the target of providing universal access to HIV prevention, treatment, care and support by 2010, will be reached.
After experiencing the lamentable denial of fundamental social justice to the people, the deplorable healthcare services in Nigeria, the devastating effect of the civil war, and the ferocious and disastrous effects of the HIV/AIDS epidemic, I decided to do something. During the Civil War (1967-1970) I watched children and elderly people die of malaria, common cold, diarrhea, kwashiorkor and, above all, gunshot wounds. There was no medical treatment for the sick or those wounded nor was there sufficient food. Consequently, I buried several children and elderly people daily. In the 38 years after the war, things have not improved very much, especially in regard to health care. Infant mortality is still very high and the HIV/AIDS epidemic has worsened the health care environment in most parts of Nigeria.
"...St. Anthony Children’s Hospital, Umunama-Mbaise became a reality."
In 1994, the need for a children’s hospital in my village of Umunama, Mbaise, became one of my priorities. I had three very important goals: First, to provide primary health care for the poor, needy and sick children who died daily from preventable and curable diseases. Secondly, to provide necessary facilities and amenities such as housing, water, a power generating plant, and food, all considered common goods in social justice. Finally, I wanted to initiate a vehicle for malnutrition prevention, health education on preventing disease, and HIV/AIDS awareness. I had all these planned, but the big question was where the money would come from. I never stopped praying for enlightenment. At the time, I was working at the San Antonio State Hospital as a Chaplain and Director of Chaplaincy Services. One of our psychologists at the hospital passed away and a week after his funeral service his wife, who was also a nurse at the same hospital, came to talk to me. Little did I know that she came with good news. She told me that while her husband was alive, he wanted to give a donation of $5,000 to a charitable organization in Africa. She asked me if I knew a good one, especially one that took good care of poor children. I asked her how much time she could spare and she told me she had just gotten out of work. So I told her about my proposal. To my great surprise she said, “When you want to go to Nigeria and start something, I will pay for your flight ticket, too.”
Two weeks later, I was on my way to Nigeria. That same year, St. Anthony Children’s Hospital, Umunama-Mbaise became a reality. With the help of other friends and well-wishers here in the Unites States and elsewhere, the hospital opened in 2003. The biggest highlight of the hospital is the water borehole. The villagers used to travel three miles to the stream to get drinking water. But now they get water from the hospital and free medical treatment most of the time. Here are some comments from some of the workers and patients. It has to be mentioned at this point that this hospital treats adults as well. In an interview with the matron, Rev. Sr. Esther Ikedinobi about the motive for free medical treatment as well as the growth of the hospital, she said that the aim of the free treatment was for the benefit of the people, especially the poor and the less privileged in our society. She explained that initially, the hospital was meant for children only, but now it is open to everybody both young and old. Speaking at the event also was Mrs. Victoria Uhegbu from Ezuhu Nguru as one of the parents who brought their children for medical treatment. She expressed gratitude to God Almighty for the wonderful gift of the free treatment. Another woman interviewed was Mrs. Juliet Onuoha from Umunama who said that the programme was the first in history to be recorded in the area. She said that the hospital was a thing of joy for the people of Umunama, she added that the hospital has no comparison with other hospitals within the region because they have original and foreign medication.
"She said that the hospital was a thing of joy for the people of Umunama..."
The hospital receives financial assistance from various sources, including the local bishop and overseas donations. Such donors are directly practicing contributive justice and indirectly working for peace. As Pope Paul VI stated, “If you want peace, work for justice.”
The hope for stopping more deaths among the people with HIV/AIDS seems to depend heavily on the availability and accessibility to antiretroviral therapy. “Urgent action by Government can save 3 million lives of people living with HIV/AIDS by 2015, reduce the number of orphans and prevent new infections.” The Sisters and doctors at the St. Anthony Children’s Hospital Umunama-Mbaise are poised to provide fundamental health care, immunizations, education on HIV/AIDS, and preventing teenage pregnancy. Social justice and health care issues in Nigeria still need extended therapy before a final and mutual resolution can be achieved. But we have made a start.
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