·THAT OUR CHILDREN WILL NOT DIE: PART II

An Inaugural Lecture delivered at theUniversity of Lagoson Wednesday, 3rd April, 1985.

By

OLi KOYE RANSOME-KUTIProfessor of Paediatrics and Primary Care

LAGOS UNIVERSITY PRESS1~5

14365

LAGOS UNIVERSITY PRESSP. O. Box 132,

Univ rsity of LagosLagos, Nigeria.

© o. RANSOME-KUTI

First Published 1986-All Rights Reserved

ISBN 978-2264-60-1

Printed at the Lagos University Press

THAT OUR CHILDREN WILL NOT DIE: PART II

WHEN I received the Acting Registrar's letter inviting me togive my Inaugural Lecture last December, I offered to give avaledictory lecture which he promptly rejected because therewas no provision for it in the University Regulation. Perhapsit should be instituted. The rapid changes in the economicand social life of Nigeria must affect the philosophy andresearch pursuit of any academician during his tenure ofservice. Many will learn from the processes which producedthe change. For example, I w~s appointed Professor ofPaediatrics in 1~70. In 1979, the University added PrimaryCare to my title. This lecture, therefore, inaugurates the chairof the Professor of Paediatrics and Primary Care indicatingthat a change had occurred in my philosophy, practice andresearch pursuits in the care of children.

I chose the title That Our Children Will Not Die for myInaugural Lecture in 1974, but, due to circumstances in theUniversity, it could not be delivered. I thereafter used it asthe title of a film on Primary Health Care made by theInstitute of Child Health in 1976. That was Part I. Thislecture is Part II, because the reasons for choosing the titleat that time remains the same.

The earliest medical services in Nigeria were pre-occupiedwith the eradiction of malaria and improved environmentalsanitation. Scant attention was given to children. From1900 onwards, small hospitals and dispensaries were in evi-dence in towns to care mainly for European civil servants andarmy personnel. Missionaries provided services for theindigenous population in the rural areas. By 1925, LordLugard, referring to the European population wrote:

"The diseases of Tropical Africa are comparatively few;black water fever, malaria, dysentary and anaemia are theprincipal ones. Lung disease, enteritis and cholera are rare oruncommon among Europeans. We have now, in the Tropics,a most efficient medical service, and, generally speakingexcellent hospitals with an adequate nursing staff. To theskill of the doctors and the improvements they have effected

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in sanitation etc., it is due that the returns of deaths andinvalidings now show such a wonderful decrease" (Schram1971)

Ralph Schram, the historian of the Nigerian HealthServices commended: "Lugard indoubtedly felt that theadvances were wonderful; but for 9.5 million Africans inNigeria, the day of excellent hospitals and improvementsin sanitation was still far off". Need I say more!

The first School Health Services were begun by Dr. I. L.Oluwole in Lagos in 1925. Around 1926, maternal and childwelfare services were established in the rural areas by mission-aries. In those days, it was noted that deliveries often tookplace on the mud floor, in dark, smokefilled and overcrow-ded rooms. They were supervised by grandmothers whofrequently introduced puerperal sepsis, and the babies leftunattended until the third stage of labour with oozing cordsopen to infection from tetanus, a risk only increased bydressing the cord with cow dung.

In 1931, a report on health in Colonial Africa statedthat "the main factors which lead to the high infant mortali-ty rate and a high general death rate are lack of sanitation,widespread incidence of debilitating diseases such as malaria,helminth infections, schistosomiasis and venera I diseases, lackof medical care and dietetic deficiencies" (Schram 1971).It is still so to-day, with a few more additions to the list.

Vital Statistics

The collection of vital statistics became compulsory inLagos in 1863; yet more than a century later, reliable data onvital rates in Niger:ia are rare. For those that are, the methodof reporting and collection are still unreliable and moreoverthey are badly utilised; for example in 1952, the late Dr. S.L. Adesuyi, a medical statistician stressed the stupidity ofproviding 90% of hospital beds almost exclusively for adultswhen, in fact, 40-50% of the need was for beds for chi Idren.

In 1900, the infant mortality rate (babies under oneyear old) for Lagos was stated to be 450/1000 live births.

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Fifty years later it was reported to have fallen to 86/1000. In1973 it was 70/1000 as stated' by the UN Demographic YearBook' and 45/1000 by the Federal Office of Statistics (Lagos).

M~re reliable data are available from surveys. In 1965-66, Demographic sample surveys gave the IMR of Lagos as143/1000 for the former Western Region and 79/1000 forthe former Federal teritory. It must be admitted, however,that, because of the tremendous growth of the medical ser-vices and the prosperity of the people, there has been asteady decline in the infant mortality rate in Lagos and per-haps throughout the Federation.

The country's infant mortality rate is now stated as178/1000; still one of the highest in the world, and the childmortality rate (0-5 years) as 322 for males and 306 forfemales in the rural areas. That is, 40% of children burn atyear 0 wi II have died by the age of five years, the majorityof these deaths occuring in the first two years.

Paediatrics arrived in Nigeria in 1952 with the appoint-ment of Lecturers in the specialty to the Faculty of Medi-cine, University of Ibadan. Although there wereNiqerianspecialists in other branches of Medicine, there was none inPaediatrics. From then on, health problems began to bedefined mainly as they presented in hospitals and solutions,mainly curative, were found where it was possible. There waslittle concern with the problems as they manifested in thecommunity, which was their main source.

Newborns

The high perinatal mortality attests to the poor qualityof our Obstetric care. 45.6/1000 birth in Lagos (Akesode1974),60.7/1000 in Ibadan (Nylander 1971), and 52.3/1000'in Ife (Sogbannu 1979). These hospital data (except the onefor Lagos which is supposed to be for the whole city)includes the outcome of deliveries commenced by tradi-tional midwives and brought to hospital when they go wrong.

In the country as a whole, it is estimated that 80% ofbabies are delivered in a costaminated environment by

5

traditional healers and midwives or without skilled attendants.In Lagos, 38% of deliveries were conducted by tradi-

tional healers or at home (Akesode 1974). In Epe, a Lagosrural area, 90% of deliveries are taken by traditional midwives(Oshinkalu 1970), in Owo Local Government area 30% weredelivered at home by a relative or a neighbour, in a Church orby a herbalist (Alii 1983). In the Kainji Lake Area, 79% weredelivered by the traditional healer and 16% by themselvesor in religious homes (Adekolu-John. 1983).

Akenzua in 1981 found eight traditional mid-wives per1,000 population in the rural areas of Bendel State. Amongother responses he received from them, 56% did not think itwas necessary to wash their hands and 36% the perineumbefore delivery is taken; 20% would manage dangerous childbirth situations such as transverse lie and prolapsed cord, and92% breech del iveries on their own. They are often knownto fail. Asked about the methods used to resuscitate a babywho fails to cry at birth, the answers varied from "Sprinklealligator pepper on baby" (60%) to "plug the anus withfinger and pour cold water on baby" (eight per cent) and"Nothing! It's God's wish" (four per cent).

When deliveries take place in hospitals or health centres,they are discharged into the same contaminated environmentfrom whence they came within 48 hours. Thereafter, illbabies pour from the community into hospital wards wherefacilities for their care are most inadequate in space andequipment. For example in the Lagos University TeachingHospital, in 1981, 34.9% of newborns admitted from thecommunity were infected, 31.5% were premature and 19.5%jaundiced; the cause of the jaundice, in the majority of cases,is associated with infection. Similar experiences have beenreported from Ibadan (Effiong 1976) and other centres.

Five conditions account for 76% of deaths in the new-born admitted to hospitals - Neonatal Jaundice, infection,tetanus, low birth weight and congenital malformation.Except for congenital malformation, all the conditionsstem particularly from factors in the community.

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Neonatal Jaundice

.'.

Neonatal jaundice is the commonest cause of braindamage in Nigerian children apart from birth asphyxia. In1967-68, 52% of children registered in our NeurologicalClinic had brain damage due to this cause.

In Lagos, Olowe observed that mothers of jaundicedbabies admitted to the wards stated that they had usedmentholated dusting powder on the umbilical cord. Acontrolled trial on G-6-p-a deficient babies born in the hospi-tal indicated that those on whom the powder was appl iedto the umbillical cord developed jaundice more often andmore severely. (Olowe and Ransome-Kuti 1979).

Again, our studies on the cord blood of babies born inthe Island Maternity Hospital in 1973 indicated that neona-tal jaundice was also common in babies born with blood

;'group ABO incompatibility. Our data indicated that of the11,142 babies born in that hopsital in 1973, 223 would haverequired exchange blood transfusion, but were dischargedhome within 48 hours of birth. Herbalists are familiar with

; jaundice in the Newborn (Oyebola, 1983). They believe it tobe 'transferred from the mother (and occasionaly from thefather) to the baby' or caused by "shortage of blood in thenew born; fever, mosquitoes-bites, blood spilling into thebaby's eyes at birth, bad water in the baby's body andmothers eating bananas during pregnancy". They wouldtreat it by "administering concoctions or herbal medicineor by washing the baby with black soap." 1" one of these is

-known to be effective in preventing brain damage.·1~Older Children

When services were relatively free, large numbers ofvery ill children are seen in any hospital's children emergencyroom. It is the point of entry for most from the communityinto the out-patient department and for 80% of admissionsinto the wards. The conditions seen in the Emergency Roommirror the health problems in the community and is anindication that community health support systems havefailed.

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The majority of the diseaseseenin the EmergencyRoomare preventable or easily cured if diagnosed"andtreated early.But at this stageof the disease,they are not "interesting" tothe Paediatrician based in a Teaching Hospital until theyappear in their worst form. The worst affected are childrentwo yearsand below. They constituted 94% of all admissionsto the Emergency Room in Ibadan in 1968 (Familusi andSinette 1971) and in Lagos (Ransome-Kuti 1967), and asimilar proportion of "deaths. The situation remain the samein 1985"

Gastro-Ententis end Malnutrition

Bottle feeding the baby is an important causeof gastro-enteritis and a precursor of malnutrition. The decline inbreast feeding is one of the tragic situations occuring in thecare of our children. In 1968, dietary histories of malnou-rished children in Laf)os indicated that bottle-feeding withcow's milk formula Wasadded to breast milk by 100% ofmothers during the babies' first month of life (Ransome-Kutiet. al .. 1972). In 1973, Data from lbadan presented in areport to the UK Committee of the Freedom from DangerCampaign indicated that bottle-feeding was started at lessthan one month of age by 52% of the mothers and 94%introduced it by ageof two to three months. In 1981, WHOconfirmed those figures for babiesaged two to three monthsin the urban areas, but found a lower prevalenceof bottle-feeding in the rural areas.

In Lagos, the majority of mothers of malnourishedchildren bottle-fed their babies becausethey "took a fancy"to it (Ransome-Kuti et. 111.1912). In Ibadan, mothers in thecommunity" said it gave the baby "health and strength"(Orwell and Murray 1974) and in Benin, because "theirbreast milk was not enough" (Alakija 1980). But it is wellknown that early bottle-feeding may lead to a failure toempty the breast, resulting in a dampening of the "Iet down"reflex and reduced breast milk' production. The need forbottle-feeding is thereby Increased and ultimately super-venes. When, becauseof ignoranceor poverty or both, dilute

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formu la feeds are thereafter given to the baby, marasmusresults.

Added to bottle-feeding, the highly contaminatedenvironment, poor personal hygiene ignorance and thedearth of potable water supply also account for the high"incidence of malnutrition and gastroenteritis.

Oral rehydration has revolutionalised the treatment ofgastroenteritis and is gaining ground rapidly. We taughtmothers in our Primary Health Care area in Lagosto use it.After four years, our data indicate that 61% of registeredmothers surveyed knew the correct fomula for the home-made solution but only 32% of those mothers used it duringtheir child's last episodeof diarrhoea. It showeda reluctanceof mothers to take responsibility for the care of a conditionwhich, in their experience could lead to death (Bamisaiye1983). At the sametime, the dread of a depressedpontanelleis clearly shown by potients and pastesapplied to it, butwhich is not associatedwith loss of fluid and the need toreplaceit.

Most children are weaned on maize gruel, a most ina-appropriate diet, dictated by culture and ignorance, is amajor cause of malnutrition and gastroenteritis. This is inspite of the fact that there are staple food items in thecommunity suitable for weaning infants successfully.

In lIesha, the mothers of malnourished children knowthe disease protein energy malnutrition. They call it'Kosoko (no hoe) or Ori nla (big head.) They believe thechildren have supernatural powers to die and be reborn, andthat the diseaseis communicable (Ojofeitimi 1982). Nonestated "an inadequatediet" asthe cause.

The casesof malnutrition seen in the hospital are thetip of the community icebergwith a large reservoirof poten-tial casesready to be struck down by measles,tuberculosis,whooping cough and diarrhoea. Community surveys bymedical students last month in villages around Ifo indicatedthat a total of 25% of the children were malnourished'(17% boderline and eight per cent severely). ,

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Malaria and Convulsion

In clinics, fever, due to malaria is the commonestcomplaint, most frequent and severe in children between theages of nine and 24 months. By age five years the clinicalmanifestations of malaria are less severe and the chi Id hasacquired considerable immunity. In school children, deathfro_m malaria is rare, but it causes a high prevalence of morbi-dity (Fasan 1969).

This pattern is, however, changing due to the wide-spread use of anti-malarials by the people.

Th~ most severe forms of malaria are often broughtto hospitals. One form presents with high fever and pro-longed convulsions in children between ages of nine monthsand two years. Thirty per cent to 40% of them die within 72hours of admission, others recover with or without varyingdegrees of brain damage.

The disease is dreaded by parents who believe that whenthe child clenches the teeth, death is imminent. To preventthis disaster, the child's mouth is badly traumatised and theattempt to ~eep it open; shock treatment is also applied~uch as burning of the feet or buttocks or rubbing pepperInto the eyes. A mixture containing cow's urine, tobaccoleaves and several other and variable herb, demonstrated tocause hypoglycaemia in rats (Ojewole and Olusi 1976) and inrabbits (Grange 1981) and cardiotox city in cats is given tomany convulsing children. This poison is a major contribu-tor to about 60% of the deaths due to this condition.

We surveyed mothers in the community regarding theuse of cow's urine mixture; 27% gave it to their childrenregularly once, twice or more daily, on its own or mixed withherbs or other medicines, and, in the majority of cases thechild always impro~ed. The mixture is often given routinelyto pr~ve~t convulsion: so, when the child convulses, a largequantity IS poured down his throat. This is the community'sperception of a drug known to be poisonous.

Fortunately its use is considerably reduced in the urbanareas, but continues in the villages.

Judging from a very heated discussion on malariaprophylaxis which took place at the Annual Conference ofour Association in Calabar in 1983, Nigerian Paediatriciansdo not have a unanimous view on the subject. The fear was

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expressed, on the one hand, that continous chemoprophy-laxis may suppress the child's immune responses necessary toprotect him against malaria throughout adulthood; on theother hand, not to use it may expose him to a severe attackwh ich may be fatal.

An ideal prophylactic regimen would be one by whichthe child could be partially protected so that he did notdevelop a severe attack of malaria, and at the same timewould still be capable of manufacturing antibodies againstthe parasite. One such regimen was described by Morley(1971) who gave pyrithiamine monthly and chloroquinefor any episode of fever. With this regimen, the number offebrile convulsions in the children in the community wasconsiderably reduced, presumably due to the prevention ofthose caused by malaria, and at the same time, hopefully, thechildren were given an opportunity of developing immunityto malaria. Further work of this nature needs to be done.

Measles and Immunisation

Of all the infectious diseases amenable to preventionthrough immunisation, measles is the most devastating. Ahigh level of coverage with its vaccine is difficult to achievebecause of its high cost and fragility. Again, althoughmeasles immunisation is recommended at the age of ninemonths, in Lagos, for example it is estimated that 30% ormore of measles cases occur before that age, and vaccinationat six months .has often been ineffective. The fact that thechild develops measles after immunization erodes themother's confidence in the vaccine, and brings it intodisrepute.

From the evidence available in Nigeria, the performanceof our Expanded Immunisation Programme since 1976 hasbeen dismal. Jinadu (1983) evaluated it in the OranmiyanLocal Gcvernrnent Area of Oyo State and found very lowlevels of immunisation coverage for most vaccines for activi-ties carried out between 1977 and 1981. He identified thereasons for the poor performance as due to:

"(a) inadequate community participation in the plann- .ing and implementation of the programme.

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(b) poor communication between different govern-ment representatives and;

(c) inadequate publicity.

Moreover, vehicles were grounded for most of the yearand frequent power failure caused wastage of large quantitiesof vaccines which cast doubt on the potency of those admini-stered to the chi Idren ",

Alii (1984) reported that no child in Tafawa BalewaLocal Government Area in Bauchi State and only nine percent in Owo Local Government Area, Ondo State, were fullyvaccinated after three years of the programme. She foundthat irregularities in financing of the State and FederalHealth Ministries led to erratic purchase and distribution ofvaccines. She also found a lack of planning to involve thegrassroot imp lementers, and that these implementers wereinadequately trained and poorly supervised. None of therefregerators at the Local Government Office and at thetwo Health Clinics she visited were functioning because ofpower failure; the stand-by generator was also not function-ing. She saw a -Iot of spoiled vaccines due to neglect inmonitoring vaccine storage temperature and potency.

Comments

Running through this discussion is a well-known theme- that our children are so ill and die in such large numbersbecause of the inimical environment in which they live. Thehuman, socio-economic, cultural and environmental elementsof the society, therefore, needs to be transformed.

The majority of our people still believe in and utilisetraditional medicine borne out of superstition, spiritualismand the worship of ancestors ingrained in us during ourevolution over centuries. Many of us who have acquired theskills of modern scientific medicine were catapulted from atraditional past to this new era, perhaps in a generation. Justas when a pagan becomes a Christian, we tend to turn ourbacks on the past, enshrined in the community, and look tothe future _. the life and medicine of the developed world,forgetting that, even that had a traditional past, but develop-ed through a process of research and application of its results

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to the system. We have to go back to where our people areand evolve with them.

The majority of our doctors, and particularly paediatri-clan's work in the pinnacle of the health care delivery system.- the teaching hospitals, perpetually reaping the morbidharvest of the contaminated community. We do not possessthe skills to work with and transform the community to stemthe tide of ill children.

Past Efforts to Evolve Effective Health Care Systems

In 1967, perceiving the need for a new approach to theprovision of health care in the country, the Institute of ChildHealth, University of Lagos, in association with the Depart-ment of Community Health, Unilag, the Federal Ministry ofHealth, the Lagos City Council and the Johns Hopkins Uni-versity, USA and funded by many international donors andthe Federal Government, established a pilot project to evolvenew methods of health care. It started at the 'Gbaja HealthCentre, Surulere, and later moved to' Oguntolu Street,Somolu. By 1971, the. ICH team had started training SeniorNurses from various Nigerian States and other AfricanCountries who returned home to reorganise and head -Family Health Clinics along the ICH pattern.

Between 1972 and 1976, the team established modelclinics in Sokoto, Katsina and Calabar, and the process initia-ted in Port Harcourt, Kano, Ife and Abeokuta. The ICH, bythen, had had a fairly good working experience in training,service organisation, management and evaluation of healthservices.

When General Gowon announced the Basic HealthServices Scheme in 1975, we were beside ourselves with

.excitement. The services were to be set up in five years -between 1975 and 1980.

Here was an opportunity for us to participate in aunique enterprise in our life-time designed to spread healthservices nation-wide and to the grassroots in a way that itwill be sustainable by the people themselves in the spirit ofself reliance. Fortunately, we had prepared ourselves for it,we were in peak form and ready to go.

By 1978 it was clear to us that whatever advice, ski II orservices we or even WHO had to offer were to be totally

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t~ the primary health needs of Nigerians without sacrificinghigh standards of training. But have yve got a minister orcan we have a Director General of Medical Services withimagination, enterprise and proven ability who can mouldall these efforts into a vigorous national programme? Some-how, the endless symposia, workshops, seminars and con-ferences of primary health care must yeild some ground toaction in which the country's abundant manpower and otherresources will be mobilised purposefully to provide effectiveand efficient services for our people.

Without research, no country can progress. An atmos-phere condusive to research must be created. Above all, itsresults should be utilised to solve the country's health pro-blems.

In 1957, responding to a request from Prof. CollisRochefeller Foundation donated an Institute of Child Healthto the University of Ibadan which the University continuesto fund with assistance from the Federal Governmentcommencing in 1976.

At independence in 1960, again, following a request byProfessor Collis, the first Professor. of Paediatrics in LagosUniversity, Unilever donated an Institute of Child Health inevery Region to the nation which the Federal Governmentagreed to maintain.

In the Northern Region, it was built in Kaduna andwas used by that Government as an infant welfare clinic; theEastern Region ICH was built in Aba and converted into aschool for training community midwives. The £50,000 givento the Western Region disappeared, and that the Institutewas never built. When the Cameroons seceded, its share wastransfered to the Federal Territory of Lagos in 1962 whichis the Institute I now direct. Its turbulent history willsomeday be told.

In 1972, the late Aminu Kano, the Minister of Healthat that time accompanied my team to Sokoto to open theFamily Health Clinic established in that city by the ICH,Lagos in collaboration with the North Western State Govern-ment. Prof. J.F .Ade Ajayi, the Vice-Chancellor of LagosUniversity at the time was represented at the ceremony byProf. Tugbiyele. The clinic was funded by the Federal Govern-ment again, due to the efforts of retired Dr. Irene Thomas.At that opening ceremony, Alhaji Aminu Kano declared that

spurned. Money was lavished on things-buildings, equip-ments, mobile clinics to run around on land and water, butnot on people who could conceive plans, implement, andprovide the services, train personnel and set up health servicemanagement and evaluation systems. By 1982, the schemehad burnt itself out and was abandoned. Nowhere in Nigeriawere services being provided under the scheme. Those werethe saddest five years of my life. We had the money and theskill to bring relief to our people, but Nigeria was unfortuna-te to be led by people without knowledge, skill or vision.

In 1973, at the instance of Dr. Irene Thomas the Medi-cal Officer in the Federal Ministry in charge of Maternal andChild Health, I was included in an UNDP delegation toCalabar to propose a program designed to assist the CrossRiver State Government to spread Family Health Servicesthroughout the State. Dr. Ecoma, the State Chief MedicalAdviser was very enthusiastic and accepted the plan. Firstthe ICH Lagos was to establish a model Family Health Clinicin the City which will be used for training during the imple-mentation of the model rural health services. This entireproject was to be used to train other health personnel for theState-wide health service. Dr. Ecoma later left the PublicService to become director of the Project.

By 1979, all the elements of the project were in place.The city service was functioning well. In 28 villages,communities had provided space or building for villageclinics. 123 traditional birth attendants, 35 Family HealthWorkers resident in the villages and supervisory staff hadbeen trained and the system was functioning.

In 1980, during the last civil administration, the StateCommissioner of Health previously a Professor of Dentistryof this University, decided that the project was too primitivefor a modern state, and in spite of pleading from manyquarters, it was terminated.

There are however bright spots here and there in thecountry today. UN ICEF is urging Nigeria to improve itsimmu nization coverage through the expanded Programme onImmunization conceived by WHO. Many church groups areworking in cities and the rural areas with the people to set upprimary health care systems; medical schools, particularlyUniversities of Lagos, Ife, Calabar, Ilorin and others haveintroduced imaginative curricula to prepare doctors to attend

14 15 3143 5

He integrated preventive and curative services, intro-duced the home-based record system, the road-to-healthchart, simp Ie diagnostic tools such as the arm circumferencestrip and therapeutic skills such as the use of salt, sugar andwater solution to prevent dehydration. Although he demon-strated a reduction in mortality and morbidity in the treatedvillages using very limited resources, the system rapidly dete-riorated after his departure because there was no governmentand community participation (Cunningham 1978). Of thetwo, the latter is the key to the transforTation of a commu-nity for the delivery and maintenance of effective healthservices. Cornrnunitv participation means that the citizenscontrol the process of transformation whereby they mobiliseand act to improve the quality of their lives. In this process,existing social structures or those created for the purpose,such as village health or development committees, must bethe medium and appropriate health technology utilised,which, as much as possible, must be transferred to the mern-bers of the community. On the other hand local technologiesfound to be effective should be encouraged; for example, theHausa cut the umbilical cord with a red hot knife; for thisreason, tetanus is said to be relatively uncommon in theirnewborns. At all times, the aim is to develop the spirit ofself-reliance within the community and incorporate patternsof scientific health care into the traditional system. Properlymotivated, the community will take action in its own interesttowards the achievement of better health.

In Garkida, Northern Nigeria, the villagers built theirhealth clinics and sponsored a man and a woman to trainwith the medical mission of the Church of the Bretheren asvillage health workers, and are supervised by them aftergraduation. These village health workers are able to treatcommon ailments such as cough, fever, diarrhoea, skin con-dition etc., mobilise the community for preventive massaction such as the construction of wells and latrines and canalso immunise children.

Mothers are our best ally in this enterprise. It is theuneducated women - and they are in the vast majority,who bears the largest number of children and loses the most,who fails to understand simple concepts such as the meaningof the growth chart, and performs worst of all in bringing herchild for immunisation even when the services are made

his ministry would establish an Institute of Child Heatth inevery state. About three years later, it was announced thatan Institute of Child Health would indeed be established inevery Teaching Hospital, and money was voted for the pur-pose in 1976. Since then, Institute of Child Health havesprung up in Benin and Enugu. Two months ago, in 1985,the Federal Ministry of Health has given notice of withdrawalof annual subventions to all Institutes of Child Health, thusbringing the country back to where we were before indepen-dence. This tragic decision has been taken at a time when75% of all deaths are in children caused by preventable disea-ses and those easily cured if treated early due mainly toconditions in the community, and to which problem thecountry, as yet, has no answer of its own.

Moreover, at a time when it was, at least, clear to manynationally and internationally that Specialist and TeachingHospitals were not the answer to Nigeria's Health problems,the construction of such Teaching Hospital was embarkedupon; and again in 1980 the.Shaqari administration decidedto build six specialist children hospitals in various parts ofNigeria at a cost of 40 million naira each.. The project wasactively pursued by the Federal Ministry of Health up tillDecember 31st 1983 when time and money ran out on them.

The Future

Asuquo Antia (1976), one of our distinguished Paedia-tricians, once sounded "a note of caution to all those con-cerned with child health in the Tropics that all change is notprogress and that increased sophistication does not necessari-Iy mean advancement". But the question to be asked is"What change do we need to ensure progress?"

David Morley in the early 50's worked in Nigeria andwas the first to see the need for innovations in the deliveryof child health services. Because of the shortage of doctors atthat time, he transferred the majority of the responsibilitiesfor treating the early stages of the common diseases tonurses. Since then, we have learned that even lesser trainedhealth personnel, down to the level of the village healthworker can be successfully trained to assume some of theseresponsibi Iities.

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available, affordable, accessible, and efficiently run. She issubjected to enormous social and constraints which pre-vents her from utilising the services effectively and is alsosubjected to conflicting advice from ancient and modernhealth systems regarding the care of her child. Moreover, themother is striving to function in a modern economy withinadequate and inappropriate or no educational preparation.

A refractory problem is to convince mothers of the needand efficacy of preventive measures, hence elaborate out-reach systems or community-based systems must be set up toinduce her to use the services; for example, first infant visitsto a health facility are usually for an episode of illness, oftenpast the infants age of six months when the first phase ofimmunization should have been completed, and at a timewhen the child is most vulnerable to preventable infectiousdiseases.

.Again there is evidence indicating that when adequatespacing or the reduced number of children per family isachieved, their health improve,s. For example the chances ofmalnutrition (Morley et al 1968) * low birth weight babies(Burr Hunt 111976)* gastroenterities, respiratory infectiousand a lowering of intelligence quotients is increased thelarger the family. '

It is believed that if parents perceive that their childrenwill survive due to efficient child care services, they will takesteps to reduce the size of their families.

One evidence in support of this hypothesis comes fromlmesi-Ile where Cunningham (1971) found that additionalbirths desired was less in the village with an efficient under-fives clinic than in the one without.

In Ebendo village in Cross River State, Frank Mott(19?~) concl~ded that the women compensate by havingadditional children almost exactly equal in number to thenumber of deaths they have had, and that if, in fact, childmortality can be reduced, there might well be a compen-satory one to one corresponding decline in completedfami Iy size. '

The challenge is to establish a health care system whichwill ~ouch t~e lives of every member of the community,especialtv children, who are the most vulnerable and whichwill tackl~ ~hose conditions causing the highest mortalityand morbidity. The system must be organised from the

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_, iI ~ • 1./ '" I I-

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"- ,..- .

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grass-roots, integrating preventive, promotive and curativeservices, using the type of technology which the membersof the community will accept at a level they can utilise,maintain and afford, with an efficient and effective systemof supervision and referral. It is not reasonable that weshould expect to supplant a traditional health system whichthe people have learnt to trust, is serving them well, its lan-guage understood and verdict accepted but to integrate itinto a system based on scientific principles.

Traditional medicine demands compliance throughdogma, communal pressure and faith; scientific medicinedemands reasons and proof-attributes acquired throughmodern education.

The situation regarding the health of our children is stillgrim. But it need not be so. Had I been told that in thetwilight. of my academic and professional life the wards willstill be filled with children suffering from tetanus, tubercu-losis, measles and malnutrition, that our children's brains andlimbs will continue to be damaged in large numbers bymeningitis, jaundice and poliomyelitis, I would not havebelieved it. There is one consolation, however, we now knowmuch better than before how to prevent them from dyingand being damaged. We only need to be inspired; but fromwhere will that inspiration come?

Many things can wait, the child cannot.Right now, his hip bones are being formed.His blood is being made, his senses are beingdeveloped.To him we cannot say Tomorrow.His name is Today .

- Gabriela Mistral.

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