Malaria, malaria, malaria.
Thats what I heard from every doctor and nurse I met with in Cameroon. I visited 17 health care sites, ranging from large government hospitals to rural clinics staffed by a single nurse, but at each the most common ailment seen was malaria. Some providers estimate that nearly 60% of the patients they see suffer from malaria. (Other common problems were typhoid, respiratory infections, gastrointestinal issues, HIV and STDs, and accidents.) Malaria is a problem all over sub-Saharan Africa, but Cameroon is plagued by particularly virulent strains, which can turn into cerebral malaria and kill within 24 hours of the first symptoms. Despite the prevalence and severity of malaria in Cameroon, people quite blase about it. Whereas the thought of getting malaria strikes panic in the heart of an American, a Cameroonian thinks of it as an annual ritual, like Christmas. Most people have lost track of the number of times they've had malaria and view it as a minor nuisance. However, malaria is the number two killer of children in Cameroon, after neonatal causes, accounting for 23% of all deaths for children under 5. Only 13% of children sleep under treated mosquito nets. (
http://www.unicef.org/infobycountry/cameroon_statistics.html). Among adults, malaria is the number three killer, which partially explains why life expectancy in Cameroon is 50 years, for both men and women.
The reason that so many die from malaria is not that treatment is expensive. In fact, it could hardly be cheaper. To treat a simple case of childhood malaria costs 140CFA, or the equivalent of 33 cents. A simple adolescent case costs 230CFA and an adult case 600CFA. In comparison, a 600ml bottle of domestic beer costs 550CFA. The Global Fund, the WHO, and UNICEF pour an enormous amount of money into subsidizing malaria treatment and are constantly researching, re-evaluating and recombining the medicines to make them more effective, as strains of malaria become drug-resistant.
So if cost is not the reason for lack of treament, what is? The first, of course, is poverty. While the drugs themselves may not be expensive, getting to a clinic may be. Most Cameroonians live in rural areas, where health centers are not conveniently located. To reach one people often have to walk through muddy fields for hours, or pay 550CFA for a liter of watered down petrol to fuel their motorbike, if they are so lucky to have one. In addition, people must also pay the 200CFA (or more) consultation fee just to see a nurse and for any lab tests that must be done.
The government, under extreme international pressure, has developed programs to subsidize all health costs. Highly supported by GTZ, the German aid agency, the Southwest Special Fund for Health (SWSFH) is designed to keep costs down and encourage people to use health services but this program has mixed success. Why? Well this bring us to the second reason malaria kills: skepticism.
This skepticism includes skepticism of Western medicines, skepticism of the health system, skepticism of any government related project, and even skepticism of malaria itself. Cameroonians, on the whole, believe strongly in traditional medicines, and employ natural remedies and the services of a traditional doctor (a.k.a. a witchdoctor) as their first line of defense against illness. While herbal medicines may well work sometimes, the usually just serve to delay people seeking treatment in the Western health system, as they wait to see if their symptoms abate. Other people are reluctant to see a doctor or nurse, but believe in the power of Western medicines, and so they self-treat by buying drugs from street vendors. These drugs are usually expired, mislabeled, and sold at exhorbitant prices. Whereas a paracetamol (Tylenol) is sold under SWSFH prices at 2CFA, a street vendor often charges 100CFA a tablet, claiming it is a fancy, powerful, cure-all drug. While self-treatment can sometimes be harmless, most of the time it does a great deal of harm because, again, it serves to delay real treatment. And in the case of fast-acting cerebral malaria, such a delay can be deadly.
As for the health system and the government, Cameroonians have legitimate grounds for their lack of trust. Cameroon is rountinely rated one of the most corrupt countries in the world. In 2006 they came in 138th in the world, right behind Zimbabwe in Transparency International's annual report. As Postwatch, another anti-corruption organization wrote "Corruption in Cameroon is a living thing, a monstrous slimy hydra: vicious in outreach, cancerous in spread and disgusting in reach." I'm not sure the hyperbole is necessary, but it is fairly accurate. There are anti-corruption drives going on in the government, but when your president has been in power for 22 years and is the hand-picked successor of your first president, there isn't must motivation to clean things up. Earlier in the year the Minister of Public Health was brought down in one of these drives as evidence that the government is taking action. He allegedly pocketed about $12-$13 million dollars of international donations intended for HIV/AIDS treatment. Most likely this was a drop in the bucket of funds he embezzled during his tenure, but it still represents enough money to treat 36 million cases of childhood malaria (in a country of 17 million). For another example, look to the post office system. According to my friend Mr. Oben, a retired professor, years ago the post offices in Cameroon used to serve as credit unions, where people could save their money. Then, suddenly, all the money was gone- embezzled by various post office officials. And the people had no recourse to get their money back. So of course they are wary of doing anything that involves them, their families, their health or their money with the government, even if that means potentially endangering their health.
The widespread corruption in Cameroon has severely inhibited the development of the health care system, as well as people's willingness to use it. Government health centers have sprung up around the country but these centers are little more than concrete rooms and lack running water, electricity or sanitation, or even basic supplies such as needles, gauze, foreceps and kidney dishes. The roads to these health centers may be impassable, or may even not exist. Usually staffed by nurses, they receive little supervision, which allows for mistreatment of patients, and corruption by the staff. Because typically only 1 nurse (the Chief of Post) gets paid a meager wage, the rest are volunteers. However, they may receive a small stipend to cover their transportation costs out of whatever profit the health center makes that month. In order to make a profit, these centers often charge for unnecessary lab tests and services. Nurses sell drugs to patients out of their own purses, charging them exhorbitant prices and with-holding the drugs if the patient refuses to pay. While this behavior seems despicable, it is hard to criticize a nurse who, because of encouragement from her government, went to nursing school, only to find a dearth of paying jobs when she graduated and still has to feed her family. (By the way, that $13 million the Minister embezzled could have paid the salaries for 1 year for 14,000 nurses.)
Despite all this, during my tours of the health centers I met many dedicated, hard-working, caring and competent nurses. The story of one nurse in particular sticks with me. She was a well-trained nurse who had been placed two years ago in a new rural health center, by herself. The center had several rooms, was bright, airy and clean but lacked water or electricity. When she was placed there she was given just a desk, a chair, and a lamp. (The lamp strikes me as particularly useless, given the lack of electricity.) No beds, no supplies, no medications. (The large pharmacy room remains unstocked to this day.) For the first year she delivered babies on her desk, in the light of a bushlamp she purchased herself, with drugs and supplies she begged from other health centers, and having to run to the latrine 30 yards away to dispose of the waste, leaving the woman alone. Eventually she was given one rusty bed frame with a torn plastic mattress to use as her delivery bed. Now she goes door to door to check on the villagers since no one wants to come in to the clinic, and why would they? No one wants to deliver on a desk when they can deliver in the comfort of their bed at home, and no one wants to go to a nurse for a diagnosis when they have to go somewhere else to buy drugs. Frustratingly for this nurse, the clinic down the road, in the same health district, is overflowing with beds, supplies, and staff.
Here's another example of the misallocation of resources for you. A nurse at a small rural health center was seeing a lot of women who were experiencing complications during delivery and who needed to go to the district hospital for more advanced care. She applied for funds from an international aid agency to help alleviate the problem. They gave her a motorcycle, intending it to carry a full-term woman in labor and a nurse. And the nurse cant drive a motorcycle. Isn't development work hilarious?
On a less humorous and more frightening note, I must tell you about Dr. E, the single most insane person I met in Cameroon. Dr. E is in his late 30s and considered quite successful. He owns his own clinic, which has inpatient wards for men and women, a pharmacy, a lab, a delivery room, and a surgery theater, and employs ten nurses. But, like many incompetent and lazy doctors, he is scalpel-happy. He loves to do surgeries because they rake in money and he doesn't have to spend a great deal of time figuring out what's wrong with a patient. And Cameroonians believe in surgeries (if they believe in Western medicine) and are willing to pay for them so Dr. E markets himself as an efficient, inexpensive surgeon. He claims that while, yes, malaria is the most common illness he sees, appendicitis is the second most common. And herniated disks the third. Not a single other provider put either of those in their top ten most frequently seen illnesses. He charges 40,000CFA for each of those surgeries ($95), including post-op treatment and inpatient stay. Since the clinic opened in 2005, he has done 1,200 surgeries, sometimes as many as 10 a day, and seen 20,000 patients. (For those of you doing the math, that's surgery on 6% of his patients.) Dr. E is very proud of his surgeries, so proud in fact that
he stores the organs/tumors/entrails of every surgical patient he's ever had. And he stores them in his surgery room (which has just one bed with a plastic mattress and a table of unsterilized equipment) in plastic buckets. They are crammed in together with just enough formaldehyde to keep them from reeking. And he will gladly, proudly pull them out to show you and explain the origin of each piece. So note, if you ever go to Mamfe, Cameroon do not under any circumstances, even if you actually have appendicitis, go to Dr. E. Your organs will end up in his buckets and you will contract a post-op infection, like most of his patients do.
But besides that complete psychopath, most of the providers I met were trying hard to provide the best care they could for their patients, while at the same time struggling to get by themselves. The system is highly inefficient and corrupt and the health problems Cameroon faces are enormous. But slowly progress is being made, and hopefully a new goverment will be able to improve the system, increasing access and quality of care for all its citizens.
For those of you who are interested (and apparently you are since you've read this far), I wrote rather long, detailed but interesting report on all of this. If you would like, I can email you a copy and you can subject yourselves to an even longer commentary on the Cameroonian health system as well as 17 health facilities. Just send me your email address and I will send it out when I finish it, which will be in the next week or so.
