The Impact of Politics and Neglect on the Delivery of Health Care Services in Liberia
By Siahyonkron Nyanseor
January 21, 2004
Editor's Note: Mr. Siahyonkron Nyanseor was invited by the organizing committee of the International Federation of Medical Students (IFMSA) USA to serve as a presenter at its National Assembly, which was held in Chicago, Illinois on January 16 - 18, 2004 at the University of Illinois. The theme of the National Assembly was "Advancing Global Health through International Collaboration." Due to medical reasons, Mr. Nyanseor could not attend. However, his paper entitled: "The Impact of Politics and Neglect in the Delivery of Health Care Services in Liberia" was submitted through the National President Mr. Raj Panjabi for discussion on Saturday, January 17, 2004. Find below the paper in its entirety:
Recently, when I was asked by the organizing committee of the International Federation of Medical Students Association (IFMSA) - USA to make a presentation regarding the Health Delivery System of Liberia, I asked myself whether such a system exists in Liberia. If so, how did it function in the past and how does it function today? The answer I arrived at was not encouraging. Based on my findings, I decided to probe further in order to find out the reason why most African nations, more especially Liberia, have not made health care delivery a number one priority? Since Liberia is emerging from a seven-year civil war, the emphasis on health care would have been the right policy to implement. In my attempt to find answers to these questions, I looked at several documents, one of which is the 1948 Universal Declaration of Human Rights. Article 25 of the Declaration provided me with important answers. The Declaration reads:
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 and medical care and the right to security in the event of…sickness, disability…
As a result, I chose to look at health care as a human rights issue. Therefore, I selected as my topic: The Impact of Politics and Neglect on the Delivery of Health Care Services in Liberia. In addressing this topic, I examined the following areas: The World Health Organization (WHO) and Related Organizations, Government's Role in Health care Delivery and The Liberian Experience. In my conclusion, I recommend the health care delivery system that I feel is good for Liberia and the necessary training required to improve the basic health care services. I also recommend the customer-service focus that health service providers must demonstrate if they are going to effectively provide quality health care services to Liberia's citizens.
Now let's take a look at the World Health Organization (WHO).
WORLD HEALTH ORGANIZATION
The language of WHO's Constitution has inspired provisions of several treaties. The Preamble reads:
The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, and economic or social conditions.
As the result of the above, the following international conventions were derived from it. For example:
· The INTERNATIONAL CONVENANT ON ECONOMIC, SOCIAL AND CULTURAL RIGHTS - Article 12 (1): The States Parties to the present covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.
· The CONVENTION ON THE RIGHTS OF THE CHILD - Article 24 (1): States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health.
· The AFRICAN CHARTER ON HUMAN AND PEOPLES' RIGHTS - Article 16: Every individual shall have the right to enjoy the best attainable state of physical and mental health.
· The CONVENTION ON THE ELIMINATION OF ALL FORMS OF RACIAL DISCRIMINATION - Article 5 (e)(iv): provides that States Parties undertake to prohibit and eliminate racial discrimination in the enjoyment of "the right to public health, medical care, social security and social services."
· The CONVENTION ON THE ELIMINATION OF ALL FORMS OF DISCRIMINATION AGAINST WOMEN - Article 11 (1)(f): provides that States Parties shall take all appropriate measures to eliminate discrimination against women in the employment of "the right to protection of health and to safety in working conditions, including the safeguarding of the function of reproduction."
· The AMERICAN DECLARATION OF THE RIGHT AND DUTIES OF MAN - contains the following language: Article XI: Every person has the right to the preservation of his health through sanitary and social measures relating to food clothing, housing and medical care, to the extent permitted by public and community resources.
The important WHO and UNICEF Declaration of Alma Ata adopted at the International Conference on Primary Health Care in 1978, also used similar language:
The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.
From these various declarations, one can safely conclude that health care is a human rights issue. Professor Theo C. van Boven, then Director of the United Nations Division of Human Rights and a Professor of International Law, shares this belief. In a paper he submitted to a workshop entitled "The Right to Health" at Limburg University (The Netherlands), he used the term "right to health" to refer to provisions in the founding documents of international human rights law.
Professor van Boven went on to say, "Three aspects of the right to health have been enshrined in the international instruments on human rights; the declaration of the right to health as a basic human right; the prescription of standards aimed at meeting the health needs of specific groups of persons; and the prescription of ways and means for implementing the right to health" (U.N. GAOR Supp. No. 49 -54-55).
In view of the above, the right to health care becomes the same as that of the "right to property," "due process," "natural justice," "equal protection," and the rights to freedom of expression and freedom of association.
This brings us to the main subject of our presentation: The Impact of Politics and Neglect in the Delivery of Health Care Services in Liberia. At the onset, I asked the following questions: Does a health care delivery system exist in Liberia? And if so, how did it function in the past, and how is it functioning today? I went on to say that based on the available materials that I reviewed, what I saw was not encouraging. Let' us look at the role that any government is supposed to play in the provision of quality health care to its citizens.
GOVERNMENT'S ROLE IN PROVIDING HEALTH CARE
The obligations to promote and protect the right to health which are incurred by states through ratification of treaties are as the Scottish philosopher Tom Campbell notes, ‘Working out the specific implementations of general statements of human rights is a necessary move if rhetoric of human rights is to have a major impact on the resolution of social problems."
For example, the hearing on the Right to Health organized by the United Nations' Committee on Economic, Social and Cultural Rights (henceforth "ESC Committee') on 6 December 1993, is one of the rare occasions on which this question has been considered by a UN committee. The ESC Committee, which monitors implementation of the Economic Covenant, invited interested organizations and individuals to present their views on the scope of, and obligations relating to, Article 12 of the Economic Covenant. This article provides that States Parties "recognize the right of everyone to the enjoyment of the highest attainable standard of physical and medical health."
A number of speakers at the December 1993 hearing on the right to health noted that, despite WHO's exemplary work in developing goals and indicators through the Primary Health Care Program and the program of health by the Year 2000, the goals are far from being achieved. Much remains to be done to focus national and international attention on the promotion of the right to health. However, all states have obligations under international law regarding the right to health and that measures that are not costly can be taken to improve health status. For example:
Therefore, health care should become one of the most important concerns, if not the primary concern of every nation. This concern also includes the protection of the environment because the physical environment is one of the key determinants of human health. The human cost of environmental degradation has spurred a strong international movement to link environmental protection with human rights. This trend can be seen both in growing awareness of the need for sustainable development and in the recent emergence of a new right: the right to a healthy environment.
The 1972 Stockholm Declaration supported the view that the environment should be protected in order to ensure established rights, such as the rights to life, health, personal security, suitable working conditions, and private property, for current as well as future generations.
While there are strong policies and laws to protect the environment in developed countries, that is not generally the case in developing countries in Latin America or Africa. As a matter of fact, developed countries are partly responsible for some of the problems in the developing countries. One such example is the dumping of their toxic waste in Third World countries.
Having said that, I would like to reiterate the focus of this presentation, which is on Health Care System Delivery in Liberia, West Africa.
HEALTH CARE DELIVERY: THE LIBERIAN EXPERIENCE
From the inception of the Republic of Liberia, very little attention and resources were allocated to health care. In fact, it was epidemics such as Malaria, Yellow Fever, Yaw and Smallpox that made it almost impossible for the Settlers from North America to make Liberia their permanent home. One would have thought that since this was the case, when the Settlers finally adjusted to life in Liberia, the provision of quality health care would have become their number one priority. But that wasn't the case! The same is true even today. Health Care is still not a priority. During the Taylor Administration, health care was assigned a very low priority.
As the Pan African News Agency reported on December 6, 2000, "Liberia's health minister, Dr. Peter Coleman sent shock waves across the country Wednesday when he announced that ‘less than 25 doctors' were running the nation's public health sector." The article went on to say, "this is peculiar, but more doctors are leaving the public health sector due to poor incentives."
Dr. Coleman added that "prior to the war in 1989, there were about 400 trained medical doctors working for the government, but the number reduced to 87 by 1997 when the Liberian civil war ended with the holding of presidential and general elections. But three years following elections, public health service delivery seems to continue a nosedive as ‘poor incentives'…drives away Liberian doctors."
Dr. Nathaniel Bartee, then Liberia's chief medical officer said, "The highest paid doctor in the public sector makes 100 US dollars, while the majority earn between 75 and 85 dollars monthly".
After World War II, medical missionaries and the Firestone Plantations Company played a principal role in popularizing modern medicine in Liberia. By 1962, about 100,000 individuals had been served by the medical facilities of the Methodist mission established some 30 years earlier at Ganta. During this period, the Liberian Government Hospital in Monrovia, the Lutheran Hospitals in Zorzor and Suakoko, the Protestant Episcopal Holy Cross Hospital in Kolahun, and especially, the national Public Health services were active in providing health services to the population. In addition, expert study groups, technical personnel and funds under the various foreign aid projects assisted these facilities. The participants included the World Health Organization, the United Nations Children's Fund (UNICEF), and the governments of Israel, Germany and Italy (Roberts et al, Area Handbook for Liberia - 1972: 97-99).
During this period, poor sanitation services led to the widespread of houseflies and other illnesses. As the result, many people contracted gastrointestinal illnesses such as bacillary dysentery. Hookworm was fairly common then too. Several forms of filariasis are endemic; and skin diseases and tropical ulcers were common. But with modern control measures in place, the dangers of diseases like Malaria, Yellow Fever, Yaw and Smallpox that once caused serious epidemics were reduced (Ibid. 96 & 98).
One would think that with a level of success against these common illnesses, the Liberian government would have continued to build on the programs that yielded such success. Instead of improving these practices, however, the Liberian government provided very little attention to health care in its policies. As a matter fact, the government did not consider health care as a human rights issue. Why did the government take such approach? In searching for answers, I came upon two reasons why the Liberian Government chose to overlook health care as a priority:
1) The general neglect is due in part to the lack of concern for the ordinary citizens by Liberia's policy makers, and
2) Since they could afford health trips abroad for themselves and their families, they did not place high premium on health service delivery within the country.
The following cases cited
below will support my claim. The first one I refer to as the Government
In the 1960s, the Tubman Administration embarked on a scheme in the name of development. During this period, the government built several public toilet facilitates. These facilitates were commonly referred to as "Government Toilets." These Government Toilets were constructed in urban and poor neighborhoods. Whatever process was conducted in selecting the sites to build these toilets, it never included the residents of these areas in the planning phase. Moreover, these facilities that were supposed to improve the health and living condition of the community, in fact, did more harm than good. The Government Toilet development scheme was a health hazard. For example, each toilet had a separate area for male and female. However, the toilet was built in such a way that it did not provide privacy for the individual. Each area contained about four stalls without toilet seat covers. And it was not uncommon for four persons to occupy all four stalls while several other persons stood in line waiting their turn.
Whenever there was a problem that caused a back up in the sewer system, it took forever -- about 3 - 7 days -- to have the problem fixed. During the breakdown period, the residents of the community had to put up with the "Pupu" smell - or the smell of feces. To add insult to injury, the water the residents used for cooking and drinking was taken from pumps, located outside of these toilets. Due to the proximity of the toilet and the pumps, the water was easily contaminated by germs and bacteria transmitted through the air and by flies and other insects that frequented the open stalls.
With all of these unhealthy conditions, the government took pride in portraying the Government Toilet scheme as a major development designed to improve the lives of the Liberian people. Nonetheless, the hypocrisy about the whole scheme was that none of these Government Toilets were located in the community where those who made decisions to have them built resided.
The second area of concern is the country's environment. There was no apparent regard for the environment.
The Liberian-Swedish American Mining Company is a joint venture known as LAMCO. Its Iron Ore Palletizing and Washing Plant, located in Lower Buchanan, Grand Bassa County, is another case in point. This is another example in which those who are supposed to represent the interest of the Liberian people demonstrated total disregard for the safety of the environment and the health of their people. In short, they represented their own selfish and shortsighted interest.
For instance, prior to the construction of the Palletizing and Washing plants the beaches along the Atlantic Ocean were places that those who lived near the coast took pride in. These beaches were not only used for recreational purposes, they served as a major source of food. Fish that was part of the Liberian people's diet was drawn from the waters of the Atlantic Ocean. Whatever arrangement or agreement LAMCO and the Liberian government had unfortunately did not include the protection of the Atlantic Ocean and the environment, nor even the safety and health of the people. LAMCO was given carte blanche to dump the waste from the iron ore into the ocean.
Over time, the Atlantic Ocean became polluted and the natural oceanic environment destroyed. LAMCO removed tons of sand from the shores of the Atlantic for construction purposes. The adjacent communities suffered from the erosion of the beaches. Perhaps, if a study had been conducted regarding the effect the fish consumed from the ocean had on the population; the result would have been alarming.
The LAMCO experience can be applied to Bomi Hills (called Bomi Holes by the Liberian people), Bong Mines, South Beach, West Point, Point Four, parts of New Kru Town, and Public Health Pound, commonly referred to as PHP. These areas were also affected by erosion caused by the removal of sand for construction purposes. Both the government and the companies they contracted with failed to examine the impact of beach erosion on the overall environment and they failed to plan for or address the problem of erosion or its effect on the country's residents. The current environment issues are: the tropical rain forest is subjected to deforestation; soil erosion; loss of biodiversity; pollution of rivers from the dumping of iron ore tailings and of coastal waters from oil residue and raw sewage.
There are other public health issues in Liberia, which I have not yet addressed in this paper. Many of these public health issues are driven by traditional practices and the lack of health education in a country where most citizens are uneducated or undereducated. These issues could be reduced by education and training if there were enough public health nurses and para-nursing support in the country. Two such issues, for example, are the sale of cold water and communal eating.
As in American Culture, "everything about the African Culture isn't that good," says Mr. Amunyahn Flama Kai. This brings us to the way things were when we were growing up in Monrovia. Unfortunately, in many homes and households, these situations still exist. The first is the way and manner "Cold Water" was sold in the streets of Monrovia. Back then during the summer, "Herenow" boys or girls would sell water, carrying buckets (containers) of ice water for sale. The water was served in a cup. The same cup was used to serve everybody who bought water. Their way of sanitizing the cup was to rinse it off in another container to serve the next customer.
The other aspect is the practice I call, Communal Eating - eating from the same bowl with either your hand or spoon. In an urban community or up country, it was a practice to serve the food for the boys or girls in a big bowl from which 3 to 4 of persons ate from, either with spoons or their bare hands. Adults also ate communally.
Back then, we used the phrase that goes like this - "No germs in Africa". An excuse we used when our "Karla" (a kind of hush puppy) or groundnut fall on the ground in order to pick it up from the ground, wipe it on either our shirt or pants and then eat it. I believe that children practiced that here in America, too. I have heard that they would wipe it on their shirts and kiss it up to God. They thought somehow that doing so sanitized the food they had dropped.
The communal eating, drinking from the same cup and wiping a Karla off after it had fallen on the ground and consuming it creates a serious health problem. No amount of hand washing or wiping off food that has fallen on the ground will keep it from containing bacteria. "Everyone has millions of germs on their hands. Most of the bugs are harmless, but some can cause illnesses such as colds, flu, or diarrhea", says Denise Mann of WebMD.
In an article entitled: "When Clean Isn't Clean Enough", Roxanne Nelson wrote: "Mom was right when she told you to wash your hands before eating. Hands carry a lot of germs, which can be spread to both you and others. In the medical world, proper hand washing has long been known to be a powerful factor in reducing the spread of infections. However, sometimes good hand washing may not be enough, as a research team recently discovered" (WebMD: Sept. 6, 2000).
While the practices that I alluded to may seem harmless, they were major contributing factors in passing on diseases and other bacteria in Liberia and most developing nations. With proper education, these practices or habits could be broken. It is a matter of LIFE or DEATH. It is that simple!
CONCLUSION AND RECOMMENDATIONS
"Humanity has many good reasons for hope in the future. Such an optimistic view must be tempered by recognition of some harsh realities. Nevertheless, unprecedented advances in health during the 20th century have laid the foundations for further dramatic progress in the years ahead," says the 1998 World Health Report. While the preceding statement is true, it is not applicable in most cases to Africa, and Liberia in particular; because quality health care services in most African countries continue to decline due to the lack of such essentials as safe water supplies, adequate sanitation facilities and the appropriate government policies regarding health and the environment.
Moreover, experience shows that reduced spending on controlling infectious diseases have caused diseases to return with a vengeance, while globalization - particularly expanding international travel and trade, including the transportation of foodstuffs - increased the risks of their global spread.
The World Health Report (1998) emphasized that "developing countries will face even more serious challenges, given their economic difficulties, the rapidity with which populations age, the lack of social service infrastructures, and the decline of traditional caring provided by the family." And in the case of Liberia, human, economic, education and environmental factors play an important role in providing quality health care services. For example, in the government's 1999 budget of US$64 million, over 13 percent was allocated for security, while only 6 percent was allocated for health care when this was one area that needed the most serious attention because of injury, disease and illnesses as the result of the civil war and the attendant starvation of the country's citizens.
The health policy of the Taylor Administration supports the claim I made earlier in this paper. I still feel that the Liberian Government's approach towards health care service delivery was shaped by policy makers' total disregard and concern for the ordinary citizens of Liberia while they used the tax money of the people to seek health care in America or Europe without compunction.
Some years ago in the 70s, I was told a story which, involved Senator Frank Tolbert, the President pro tempo of the Liberian Senate who was also the senior brother of President William Richard Tolbert and a renowned physician who happened to be a product of the A. M. Dogliotti College of Medicine (Liberia). As the story goes, Senator Tolbert's niece was scheduled to have surgery that required a special medical procedure. Prior to meeting the surgeon, the Senator had a conference with the Chief Medical Officer of the hospital - the John F. Kennedy Memorial Hospital (JFK) regarding the qualification of the physician that was going to perform the surgery. The Chief Medical Officer told the Senator how the physician was the best the country had in this area, and that his success record in performing this procedure was 100%. Upon hearing such good news, the Senator was elated and then requested to meet the wonder physician. When this tall black physician entered in the conference room, the Senator's facial expression changed. In Liberian vernacular we will say, "he was vex like hell". The Senator did not greet the physician. He proceeded to ask him from which school he earned his medical degree. "Young man", he asked, "from which medical school did you obtain your medical degree"? It is reported that the physician said, Dogliotti". The Senator interrupted with the question, "DoggliASS what? Immediately, he instructed his niece - "Get up, let's get away from this doggone place". And they left without saying goodbye.
If a lawmaker of a country, and for that matter, a member of the ruling elite despises his country's only medical institution, what do you expect from him and the rest of his collogues? Not to give a damn! And to confirm that perception, at one time the services at JFK Hospital were so poor and so bad that Liberians referred to the hospital as "Just For Killing".
The health care delivery system of Liberia can only be improved if the Liberian government realizes that health care is a human rights issue, and addresses it as such. The government should also allocate a higher percentage of its resources in the areas of health education and health care service delivery. Furthermore, included in its policy consideration should be pre-natal care, adequate nutrition for pre-school age and school- aged children, improving the environment, providing safe drinking water and enacting strong legislation to promote comprehensive health care and safe environment and the educational programs that would support these initiatives. By so doing, Liberia will be heading in the right direction.
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About the Author: Mr. Siahyonkron Nyanseor is a Mental Health/Developmental Disability (MH/DD) Clinical Team Coordinator employed by the Georgia Department of Human Resources - Georgia Regional Hospital at Atlanta. Mr. Nyanseor is a QMRP (Qualified Mental Retardation Professional) who for the past 25 years has served in the positions of Clinical Instructor, Behavior Specialist and Administrator. He is the current Chairman of the Liberian Democratic Future (LDF), Inc., a non-profit, non-partisan think-tank democratic and research organization dedicated to the promotion of peace, democracy, justice and equal opportunity for all and Liberians in particular. The LDF is the publisher of The Perspective web newsmagazine.