text by Magdalena Vaculciakova, photo of Juan Garay, Health team coordinator for European Commission, by Georges Drouet
“There is almost no progress on maternal health in sub-Saharan Africa, reflecting the very weak health systems. Still today at least half of all deliveries are at home with no support from health workers, often with high risk of complications,“ Juan Garay, Health team coordinator for European Commission, says. Reducing child mortality and the maternal mortality ratio seem to be MDGs that probably won’t be achieved.
There are 27 countries with no improvement as for reducing child mortality and the majority of them is in sub-Saharan Africa. What is the main problem causing child mortality in Africa?
Compared with other regions, the main attributable risk of ill child health and premature mortality in Africa is poor sanitation (leading to diarrhoea as the main killer), poor housing (for instance in-door smoke from solid fuels, causing respiratory infections), endemic tropical diseases (malaria and intestinal parasites-cause of high rates of anaemia- mainly) and low access to health services. Other also contribute, such as malnutrition and low access to safe drinking water; but these risks are even higher in South Asia yet the under five mortality rates are much lower.
Where should we start in with solving the problem?
The main approach should be through strong health systems which are multisectorial (promoting healthy environments) and provide universal access to basic health care. This requires more political commitment from countries in allocating public domestic resources to health and more international support targeting better countries in greatest need and providing more aligned and predictable support to health.
How can maternal care be improved in Africa?
Again, and even more clearly than child health, it requires good health systems but also respect to gender equality.
You worked as a clinician in some of the african countries. If talking about gender equality, how did you find the role of an african man when his wife and child are ill, facing the death?
Men are ususally detached from reproductive health issues, pregnancy and delivery, and often from child care; but there are many exceptions, the bridge in this gap is education...
How do Africans see foreign doctors?
With some sense of magic, view of power, gratitude, but always distant in understanding...
Is it difficult to follow up communities?
No, it just requires genuine sensitivity.
What did you personaly do to follow up the communities when treating mothers with their children?
For instance, I did the exercise of "community health diagnosis" : a 2-3 month intense exerercise of visiting villages, homes, schools, community meetings, walking between viallages, getting information through team work, discussing together...It is all in a book I wrote which I hope I can soon re-edit and translate. Another very important experience I believe all doctors should do, is to share a day's work with a mother in rureal Africa (the work in the house, the fields, the firewood, fetching water, cooking, washing, cleaning, resting...) : "empathy" is the key to real understanding...
Can you mention any specific feature of african communities that surprised you?
Fertility values, value given to elders, importance of spirtual believes, endurance to pain...
How do mothers in Africa cope with their children‘s deaths?
As everywhere in the world, with the deepest of sorrows. They adapt and have more children, but the impact in their lives is as profound as in any culture.
What is your personal experience with child deaths?
I experienced as a doctor the first child death out of poverty and lack of any means for treatment, when I first worked in Sierra Leone. It is the worst experience I believe one can witness in life and makes you question the global system, the distribution of resources, the lack of justice while one billion lives in abundance and obesity and one billion goes to bed hungry every day; while one billion people enjoy public health services with resources of over 2000 EUR per person, and the bottom billion barely had 20 EUR and has very low access to basic, often vital health care. The world literally lets 9 million children die every year : it would require adequate allocations from national budgets to health (around 15%) and additional 13 billion EUR from international aid, this is 1% of the money spent in 2009 in rescuing banks from their crisis due to greed, or 1% of the world's annual military spending. And it would be through comprehensive health services also covering maternal health and preventing half a million maternal deaths, and also over 20 million or premature deaths of adults.
Do you think that the way the development aid concerning health care is delivered and implemented is efficient?
Not in a very efficient way. It is not enough, not aligned with country plans and priorities, not predictable. We should change our way of working with countries. Stop deciding what is best for them from Brussels, Geneva, Washington or New York; and work in mutual trust, with good assessments, participation, dialogue, in the countries, involving the communities, and building social services accessible to all, especially to the poor. Is the health care situation in Africa more about resources and money or about people and their priorities? It is more about predictable resources, institutions being responsible for guaranteeing the right to health and communities demanding it. International support has often not respected the central role of the public service.
Would you say improving health care is one of the most priorities of African countries and their governments?
I would say with all evidence that it should be the first priority.
Can you recall any of the stories you have seen or experienced when working in Africa?
I always remember this story : In my first work as a rural doctor in Africa, I diagnosed and treated an elderly patient (as many other hundreds every month..) of tuberculosis. The patient (as most in the rural district I was working in) was very poor and had reached the hospital after one whole day walking some 30 kms, barefoot. One week after discharging him from hospital when he was slightly better, he returned walking the long distance, he came during our rest day on Sunday, to offer me in sign of gratitude, a plastic bag with bananas. I was very grateful, knowing the extreme poverty he lived in , and what this, on top of the long walk, meant to him and his family.. Two weeks later, he came again all the way. He asked me if I liked the bananas. I thanked him again but wondered if he had walked all the way just to ask me...I did not know very well what he really wanted. He was shy to tell...Finally he told me : could he have his plastic bag (old and simple, the ones we constantly throw in our society..) back...I always remember the look in his eyes when I see so much greed around...
What mostly surprised you when working with Africans and treating with them?
That deep inside, when we feel the fragility of life, we are all the same...