Dr. Francis Nubari
Doc, how would you describe the state of the health system in the country?
Generally speaking, the health system in the country is in a deplorable state that we expect at least an emergency in that area reason being that, the administration is not being administered the way it should be. Ideally, we are supposed to have a primary healthcare system, a secondary healthcare system and a tertiary healthcare system. Incidentally, the primary system is in existence in its little way but the secondary is completely in a backseat because the secondary healthcare system is supposed to be a link between primary and tertiary where, people will come, attend the primary healthcare then, if there are issues that cannot be handled at the primary level, they will move to the secondary center which, is supposed to be manned by at least two to three doctors. Regrettably, that is not the picture we have.
That is something like general hospitals?
Yes. Incidentally, they do not only exist in dilapidated structure without personnel and where there is personnel, if you have a doctor and a nurse, you may not have other facilities like a lab. You may not have staff that should make it a team and then other things that should be there to make the place at least functional-lighting system and all that-all those are not in place. And manpower is also very low in the system we are talking about. So, that is that. Now, because the secondary system is not working, the tertiary system is being overwhelmed and is also not as efficient in what they should do. For instance, one is not supposed to go to the tertiary system; maybe somewhere like UPTH or BMH with complaint about malaria. These are things that should be handled at the primary level. The tertiary hospital is supposed be a referral hospital, where you go, supposed to be less crowded, that is how it is operated in developed countries because, as you go there, you know you have kidney problem, heart problem, and you are directed to where you should go.
That is specialized need?
Yes and you have manpower saved and time in the sense that the time spent waiting for a doctor will be less. But here, it has turned into both primary and secondary because somebody will go there just because he is having fever. It is not operated like that in a developed society. And the funding is also poor. The hospital funding is actually not what it should be. But generally speaking, the challenge we now have, why our system is poor, is because the tertiary hospitals are supposed to be granted autonomy but in most of the state tertiary hospitals, this autonomy is lacking and because of that they are not functioning maximally.
The autonomy, is it still supposed to be funded by the federal government?
The autonomy, for instance, the state tertiary hospital, if you want them to be optimal the way they should be, they should be granted autonomy. In an autonomy, what happens is that the chief medical director, CMD can source for manpower from anywhere to make the place work and the person is paid from within. For instance, in BMH, they don’t have plastic surgeon, neurosurgeon, so many of these specialists and it is not because you do not have those surgeons in the state but, most of them are not from the state. And because there is no autonomy, the CMD cannot engage anybody to come. But if there is autonomy, the CMD can engage somebody to come in and by so doing, you have efficient services going on.
So in a nutshell, the state of the healthcare system in Nigeria is in a deplorable state going from funding of facilities as a system, the structure, to manpower capacity lack, and lack of motivation because a situation where somebody works in a hospital and is being paid hazard allowance of N5000 in a month and you expect him to risk his life that is dangerous, compared to a National Assembly member who is going home with N1.2million a month for newspapers allowance , the gap is such that motivation is also lacking. So we are talking about revitalizing the structure, enhancing the already existing structure, enhancing existing manpower capacity building and motivating the already existing manpower you have so the place can offer optimal service. The problem is multi-sectoral, from the structure, the manpower and remuneration and motivation that is lacking.
So what are the implications of these for us?
The implication is that the healthcare delivery to the populace will be sub-optimal because a situation where somebody is supposed to have a particular kind of service and someone knows what to do but does not have the equipment to do so, that person (patient) may be sent to India when the thing can be done in Rivers State, which is putting untold hardship , untold stress to getting a service that can be delivered within the environment. In some instances, you see that the poor keep dying from services that they would have benefitted from which is only available to the rich as the poor cannot afford it. You find that referrals would have been reduced and so also, medical tourism.
But currently, the poor hardly gets access to good healthcare because they don’t have the means of travelling outside. You saw what happened during Ebola. Because they could not travel out, look at the number that died. That is a typical picture of what happens. But in a situation where the structures were extended to keep these services, the millions of dollars that are budgeted for health are assigned to health, most of the services would have been available and both the rich and the poor would be able to access healthcare. So, the poor keeps suffering.
The implication is that one, our healthcare delivery will be sub-optimal; two, you find that you spend more time in the hospital just to access healthcare. Go to BMH, before you see a doctor-you can get there by 8am and you see a doctor by 2pm because personnel is less and the availability of materials to deliver are also limited. One person, one nurse may be taking the blood pressure of over 60 persons so before it gets to you, you would have spent three hours. So, prolonged time in accessing healthcare and sub-optimal healthcare delivery are the effects of the poor state on the people.
So where did COVID-19 meet us and will you say we have managed the pandemic well?
Well, in terms of management, we were not managing the pandemic; we were managing the effect of the pandemic on our lives. The reason is because most of the cases we had as COVID-19 positive by the time they presented, were neither here nor there because we were not really doing confirmatory tests. A lot of times what we even call COVID may not have been COVID and rather, the response in terms of COVID, the state and nation more of an emergency in the health system during that period, so we were able to cope not because …the people generally, the cooperation, the apprehension that followed this Covid helped so many persons to adapt to health saving behavior and adapt to the changes that we were meant to adapt. It is not as if our health system was so efficient. We were not that efficient or too powerful. We were not at all.
But did COVID-19 bring about any improvement to the availability of facilities in hospitals?
No it did not do that because, it was hijacked politically one, and in the hospitals, what they were going about was to host ventilators and things that are COVID specific. So, these things were provided. Hospitals were not built because of COVID because COVID Isolation centers were built. No hospital was renovated because they went to do COVID. It is only isolation centers that they actually worked on. They did not build any new hospital because they were fighting COVID, no, they did not but where they wanted to create isolation centers, they actually arranged. Those were the things they did.
You work on rural health. What have you observe as health challenges in the rural communities?
Yes, in the rural communities what has been the predominant problem in these areas is what the common man will suffer from. 70 per cent of the populace like the elderly, people from 60 years and above, commonly experience peptic ulcer, hypertension. And the reason for the peptic ulcer by the time we investigated, were drug related, drug induced. Because, when they come down with pain, arthritis and others, all they are told is go to the chemist and the chemist at that level, gives them what we call NSAD (Non-Senedial Anti-inflammatory Agents) and these are cancer causing drugs like Ibuprofen, Cataflan and all that. And incidentally, the chemist man, the way they prescribe is also dangerous because they prescribe drug for waist pain, drug for chest pain, drug for leg pain. Meanwhile, these are members of the same family with complex side effects. So because of that they have a lot of hypertensive cases, which are also common emanating from stress, the poor healthcare services that they access as these are things that should have been identified earlier before they come down to start having longstanding hypertension. Then, issues of airborne diseases, respiratory problems, diarrhea are common because of food contamination and personal hygiene.
So predominantly, for the elderly, we have more of peptic ulcer, hypertension among the Niger Delta population like in the Ogoni axis, the number of altered air quality from oil pollution, environmental pollution in skin rashes that is common within the area, chronic cough not responding to antibiotics because of prolonged exposure to air pollution and all that, these are predominant things that are common. But across the length and breadth of Rivers State, like the Niger Delta, the issue of air pollution is predominant. Cough, catarrh are common; people are aging faster because of the prolonged toxic effects of these pollutants that they are exposed to.
So what is government supposed to do to address these effects?
What of the things we propose is that government should have a modular health facility. A modular health facility is more like a cottage hospital with comprehensive services where, you do toxigenic screening such that people that are in this environment can actually be diagnosed because the problem that we have is diagnostic dilemma. Most times, people suffer from lung cancer but I have seen suffer lung cancer but they are treated with antibiotics.
That’s, they are not aware?
Because there are no diagnostic tools. You see somebody coughing blood, having issues with prolonged cough and most of them I will call pnuemoclosis accumulation of fumes and dust in the lungs, and because in most of the government hospitals you might not have any facility ,the only place they can access x-ray facility is if they go to BMH and getting there becomes a problem plus the time it will take to get to BMH .
The health problem of rural communities is age related-ulcer, hypertension; for the men there is a rise in cases of prostate related problems, urinary problems emanating from prostate enlargement. Now, breast cancer among the reproductive group is also an issue that, that is also being undermined currently. Incidentally, cervical cancer and breast cancer have not been on decline except that the awareness improved. People are seeking healthcare more than they used to. But in the rural communities, the perception is that somebody poisoned their breast because they did not accent to sexual relationship. That is it, there is somebody, I have contact with more than five persons that died from breast cancer; when they first presented, they felt they were not symptomatic. I equally knew as a doctor and opted surgery to send the thing back but they refused. They have all died.
So there is need for enlightenment?
There is need for enlightenment on breast cancer, cervical cancer. *Diarrhea illness has dropped with use of campaigns that are on. The vaccine related illnesses having to do with diphtheria, whooping cough, polio, diarrhea, etc., have dropped because of the vaccination that is on-going. But respiratory and airborne diseases have not dropped because of the environmental pollution that is prevalent around the environment. Then peptic ulcer which is emanating from the drugs people are abusing is also a problem. Hypertension is still there because of the problems people are facing. Prostate cancer is also on the rise; prostate, especially for those in their 50s especially because of the cases they present. Then childhood illnesses because of the vaccines that they are taking, child healthcare has improved mostly at primary healthcare centers.
One of the challenges that actually contributed to the increase of child mortality, was malnutrition, that is one of the things as an organization in the Center for Environment Human Right and Development, CEHRD, we identified and are curbing through our programme.
This malnutrition now, with the issue of COVID-19 is it not going to be on the increase?
Sure! You know, recently, the issue of food insecurity has been on because at the peak of the pandemic there was overwhelming food insecurity. Food insecurity abounded during the period because there were lockdowns, markets closed, agricultural produce were not transported; there was rising inflation on the little available and because of that, there was food shortage. Insecurity abounded, malnutrition was actually obvious among young children who used to eat three, four, five times a day. The (hunger) was very, very obvious and when we did the pilot programe and started in June, the heat of the pandemic, it was very, very obvious – we conducted physical, social and scientific assessment and we identified that this was very, very obvious and till date, they are…..It was not just on the part of the (children) you see teachers and parents coming with plate, begging for food and remnant from the programme on daily basis and they eat with every sense of commitment to tell you that they mean business.
That is the product of poverty in the midst of plenty…
Yes, so, things like malnutrition, we put all those kinds of things under what we call non-communicable issues because they are not contagious but they can actually be endemic in an environment based on the prevailing circumstance like what COVID did that is actually what it was. But generally, in terms of the health situation of rural people, the health situation is poor because of the faulty health structure. They must have access to healthcare services. The healthcare must have credibility, affordability, availability, accessibility. These are components of primary healthcare that they must be accessible, must be affordable. It must be available. So these are really the issues; those areas need to be optimized.
There should be an overhauling of the health system. They need to administer it because the design of health administration was that the primary healthcare system is supposed to be under the authority of the local government while secondary system should be under the authority of the state and tertiary should be under the authority of the federal. At the level of primary healthcare, the person that is supposed to be the chief accounting officer should be the local government chairman; the accounting officer for the secondary healthcare should be the commissioner for health in that state and that of the federal should be the federal minister. Incidentally, this administration structure has collapsed where the state government is not maximizing the health centres and even in the local government, some local government chairmen do not even know where the centres are, that is the problem. Because that administrative structure has not been properly harmonized, that is where the problem is coming from. So the way it should be revisited and the local government authority should manage the primary healthcare system. It will bring a lot of closenes in term of complaints and issues.
Will they not say they do not have enough money because local governments always complain of not having enough money to pay teachers, healthcare workers?
No! Those things will be set when the local government autonomy is fully implemented because the money that is allocated to them is not going directly, it is still passing through the state. Their money is not deducted from source.
Ok, let’s talk about the relationship between health and gender-based violence. What is the state in rural communities?
In terms of gender-based violence, gender-based violence is not just a public health problem; it is also a human right problem. Now, the challenge we have in the rural setting is the level of information they have about their human right because at the rural level, people are consistently being abused in rural communities and they cannot open up their mouth because, it has not been understood that this is a crime against the state. They don’t know that. They have also not understood that this is a human right problem. What they see is the strength in the perpetrator and they keep quiet. So, at the rural level, so much need to be told for them to really understand what gender based violence really is; that this is both a human right and public health problem.
What is there is that in the rural communities, they don’t even know their rights, they often conceal the abuse and that is why it is often under-reported because of the system so the thing is being under reported, many incidents are concealed. We only know because we are in the health system and because they present to us with health complaints and because they are also afraid of contracting HIV and all that and we do apply medical responses by giving them HIV/Contraceptives on emergency post trauma. We give them emergency contraception so that they don’t get pregnant. You understand?
We know. But those that are not in the health system do not know. So what happens is that so many things are happening but there are being concealed because the rural woman does not understand that it is a human right issue so because of the social stigma that characterizes it, they conceal it. It is there in rural communities.
So there’s still need for enlightenment?
Yes, there is need for enlightenment particularly, among opinion leaders. The country leadership should drive the need for community leaders to be enlightened because at the level of the rural communities, I was a consultant to one of these organizations that had funding from Kisi Health Trust last year on reproductive health and in that meeting there was a formal message to community heads. This is because the perpetrators are within the communities and a significant percentage of these communities are cultists and these cultists now are becoming so powerful in the communities because of the bunkering activities they are involved in and they are also rich. They have also gained influence even over (native) doctors and some of them even take in young girls hostage and till now they are in custody of them and the parents are begging them to release them…
So at the rural setting, community leaders need to be told, look, this is a human right issue as well as a public health problem. The community structure needs to understand that gender violence is a crime against the state; whosoever commits cannot be more powerful than the state and so should be reported. Yes, at the rural communities gender based violence needs to be addressed…
When you are talking about violence, who in the rural areas knows about VAPP Act? They have not understood it. Gender based violence is so under reported. I have attended to wives of chiefs who have been raped by young boys and they conceal it; these are the issues. Gang rape is still happening and they know the group that did it, that it is either Dewell or Degbam boys and nothing happens. And they do it on daily basis; it is not that they do it and they stop, it keeps happening. It will happen tomorrow, it will happen the day after. So, gender based violence is not just an issue but, it is an institution that needs to be addressed at the rural level.
I was even going to ask, what is the relationship between insecurity and women’s health?
Insecurity and women’s health, a lot; now, when we are talking about gender based violence you know that it may take different forms. We talk of rape because rape appears to be the commonest.
We also know that there is domestic abuse, economic abuse, emotional abuse, psychological abuse. Gender based violence is a thing of power. Someone that has more power over one person, takes advantage either economic or political power or physical power and once the environment is not secured, it is a fertile ground for the survivor. For instance, if a young lady is in an environment of 1:4 men (one girl against four boys),it is a high risk environment because in that place, that young girl is not secured. She can be abused. Now, in a community where the legislation, power of a state or local government or country head is also weak, the widow’s right can be violated and she can be abused by her in-laws, anyhow. But in a system where you have a strong standard at the community level, it is just to walk to the council of chiefs and they will address that in-law.
So, generally women’s health is more prone to an environment that is insecure because they are more prone to rape. Once there is an abuse, they are also more prone to emotional trauma, and with emotional trauma, hypertension also sets in.
Those are the issues so health and security are inversely proportioned to each other because when there is a branch of security, then there will be harm. If armed robbers enter into a place, they have breached the security of that place; somebody will be injured. That is the picture; even if the person is not injured physically that person will be injured emotionally. The effect will be that at the end of that incident, somebody may be hospitalized because of hypertension. So you discover that security and health are directly proportional to each other. When an environment is well secured, there is good sleep; when there is good sleep, there is also good health.
Tell us something briefly about mental health
You know, mental health in this part of the world is not being discussed the way it is discussed in the western world, reason being that the cultural beliefs around mental health there and here are different. For instance, when people have psychiatric problems here, the first thing that comes to mind is that there is an evil force but we also know that among the youth age, drug abuse is a major cause of mental problems. That is why a significant number of people you see that are into mental, psychiatric problems are not in the hospitals. Some of them are roaming in the villages some are also in churches because it is assumed that somebody has afflicted them. But you now discover that mental health is a whole lot of things beyond just having reactive psychosis because when you are talking about mental health, you are also talking about even insomnia. Someone who cannot even sleep is having a mental problem; someone that is depressed is also having a mental problem, excitement is also a mental issue – so you now discover how many persons are stable? Only a very little fraction when you are looking at mental health. The issue is that in this part of the world, the only challenge we have with mental health is that we have not seen it purely as a medical issue. Rather, we see it more like an affliction from the devil.
So we need to look at it as a medical issue, change our mindset?
Yes, we need to see it as a mental issue and identify it as a medical issue that can be addressed and channel it to where it should be channeled. And this is also where our spiritual leaders need to be enlightened because when everything is being spiritualized, it becomes a problem because a young man that I know that smokes and becomes mentally retarded and start fighting, we know that that person is suffering from brain stimulant that he has been taking. Then an uncle would be accused that he has said that there won’t be anyone above him in the compound and before you know it, there will be a prophecy, all kind attacking him. In addressing mental issues, we should be holistic. We should look at it from ….
Predominantly, it is among the youths, that we have drug related cases. We also need to speak to our spiritual leaders to make physical things physical and spiritual things spiritual so that the trend can drop because currently, with the level of restiveness, the mental illness has grown high among our youths.
And what should government do?
Governments have a role but the role of government should have been more delivered when the administrators of the country’s governance also have an understanding of what we are talking about. One of the days we were speaking on the response to gender based violence while addressing doctors in Rivers State, and I was speaking, one of the doctors from the Nuero-psychiatric Hospital was also present and he made a lot of proposals that touched on the inter-relation between mental health and gender based violence and you discover that they are also overlapping in so many ways. For instance, the psychiatric hospital is a hospital where mental issues are treated. How long ago was the hospital renovated? When last was it renovated? I was at the Remand Center at Iriebe sometime ago, a young boy with mental health problem whom I and David were handling there. Beyond the mental case there were also medical issues and in most cases, it is the children of the poor who are mostly affected.