No poverty, zero hunger, good health and well-being for people, quality education, gender equality, clean water and sanitation, sustainable cities and communities (make cities and human settlements inclusive, safe, resilient and sustainable). For those who do not know, these are the Sustainable Development Goals (SDGs) 1, 2, 3, 4, 5, 6 & 11.
While I was traveling to Primary Healthcare Centers (PHCs) in rural communities for supportive supervision, the issues that led the UN and other stakeholders to propose the SDGs were glaring. My task for the week in focus was to visit a cluster of PHCs in a certain ward. The closest of the PHCs is a two hour drive from the city center, and situated close to a major motorway. The rest were at least one hour from the motorway with the farthest being over two hours from the motorway (that is more than 4 hours from the city center). On day one, we were able to visit only one health facility, because even though geographically this facility was quite close to another facility (about 15 minutes on a motorbike during the dry season), we had to go round to access it from a totally different side of town, this is because of a stream separating the two communities.
The time spent on the trips was a function of both the distance and the very difficult terrain. We were only able to access those communities because our vehicle was a 4×4 Toyota Hilux, as it would not be possible for a saloon car to make it. The only other option for the members of the communities is the use of motorbikes, when the streams aren’t flooded. In some of these communities, the PHCs are the only modern structures around, some have electric cables passing close by but have no electricity.
All through the trip with little to do but admire the beautiful nature all around and think, I did a lot of thinking; interrupted occasionally by sights of human suffering and poverty. Most of my thoughts were centered around SDGs 1 & 11. I kept thinking of how we could make these human settlements I was passing through “inclusive, safe, resilient and sustainable”. It is no wonder that despite all the efforts of healthcare workers, the indices of interest remain poor. Immunization coverage has remained sub optimal, with maternal and child mortality remaining unacceptably high. The only thing these communities have going for them is agriculture, but this is still mainly subsistence farming, which can not provide the kind of empowerment needed to eradicate poverty. It is difficult to see how our interventions in the health sector would be effective and sustainable, given that most of the problems lie beyond a single sector. Without tarred roads, the fate of a woman in obstructed labor in such communities can only be bleak. A very sick child with complications relying on the Primary Healthcare Center, which are understaffed with varying levels of commitment from the healthcare workers, has a very poor prognosis. The healthcare workers at the PHC in turn complain of being overworked (sometimes a single staff runs a PHC), and that they working conditions are very poor with many many of the buildings in a sorry state. The public officials can not supervise adequately because of the difficult terrain and logistics required amidst competing needs. Even though this setting described is in Nigeria, it is a similar situation in many sub Saharan African nations. I saw a picture of a WHO team responding to the Ebola epidemic in one of the African countries and the terrain was the same; the locals were helping them to cut tree branches to construct a makeshift bridge so the team could cross and provide services to those in need of them. In contrast, while I was reading about Primary Health Care in Greece (a country that is said to have undergone severe financial difficulties), the Primary Health Care units were said to consist of multidisciplinary teams of general practitioners, paediatricians, nurses amongst other cadre of staff. This is more than many secondary health facilities have in Africa. Some will say there is no basis comparing the facilities in Europe with those in rural parts of Africa, but not doing so means we do not really intend to achieve the SDGs.
The settings I have been describing are generally referred to as “Hard-to-Reach (HTR)” communities in public health speak, but for the purpose of this write up, I would like to call them The Rural World. This is because other than being hard to reach, these people seem to have been forgotten in a different time and place. I have heard arguments about cultural preservation and the use of locally available materials to ensure sustainability, but I am not sure that in the absence of modern houses, good sanitation and clean water, with tarred roads into these communities, we can claim to have made any sustainable impact. These are the basics to build upon but they are either completely lacking in some of these rural communities or grossly inadequate. This is why we must accept that these communities exist in a different world. Attempting to paint a picture of the solutions may result in a very complex and perhaps disorienting narrative. However I am of the opinion that as a first step towards real development, providing clean water, modern houses and tarred roads with bridges such that access is guaranteed all year round will have a profound effect on rural communities. This is not just because supply of medical products and expertise will be easier, but economic benefits will follow, which in turn are directly related to health. Teachers and healthcare workers will be more likely to accept postings to these locations and oversight will be easier; farmers will also be able to get required supplies and meet demands for the their products more easily. Jeffrey Sachs in his book “The End of Poverty: How we can make it happen in our lifetime” attributed much of China’s economic progress to the provision of widespread public health infrastructure. This is because public health infrastructure encompasses a wide range of things including all the goals highlighted above out of the 17 SDGs and more. If we are truly serious about ending poverty in Africa, we must move urgently to provide these basics. Until genuine efforts are made to connect this rural world to the world we live in (which is far from perfect), we can not make meaningful progress in health, education or economic empowerment. Whenever issues like these are raised, many are quick to point out how achieving this will require significant capital (billions of dollars) and that resources are scarce. I maintain however that provision of clean water, modern houses and tarred roads in the 21st century (wherein other nations are launching rockets into space) should not be rocket science. Other interventions may be good, but are mainly temporary measures that can not be sustained without the basic foundations. While focus on national governments is in order, there is need to extend this to regional, state and local governments, which must key into the vision and take the lead, for rural development to occur. It is possible!
The last community we visited had no cellular network, and we had crossed a small stream to get there. The clouds began to gather immediately we arrived and soon it began to rain heavily, it was getting late. I tried to be as thorough as I could be, to the irritation of some of the team members, as they kept glancing at their wrist watches and making impatient moves, sometimes I ignored them but sometimes I obliged; after all we had been warned that if the stream we crossed earlier flooded, it may take three days for a motor vehicle to be able to pass through again (assuming there was no rain in those three days). No one, myself included, wanted to be stuck in the rural world for three days (or swim across to take a motorbike), it wasn’t even imaginable especially when unplanned; so I also hurried things up a bit, and of course quality of mentoring suffered. After about 4 hours we were back to our world where those who can afford it treat themselves in big public and private health facilities, and can chose to fly to Europe to handle complications more easily than a woman in the rural world with a complication in labor can hope to reach the next referral facility that actually works.
Dr Ande Elisha
The Public Health Corner