Le symbole peut-il aider à fonder une éthique?

Sawa=Nom donné à tous les peuples de la Côte du Cameroun, ou du bord de la mer.

Le Ngondo est le culte des eaux qui se fait sur la rivière Wouri de Douala  chaque première semaine du mois de décembre. Le Ngondo  appartient aux sawa (Bassaa, Bakoko, Mboo, Douala), mais les autres sont invités

E. Castelli - J. Hyppolite - K. Kerenyi, (e. a); Démythisation et Morale, Acte du colloque organisé par le centre international d’études  humanistes et par l’institut d’études philosophiques de Rome ;  Paris, Aubier, 1965.

J. - M. Aubert, Pour une herméneutique du droit naturel, dans Recherches de sciences Religieuses, 59, 1971, 449-492

 

 

Theme : ethics and health in Africa

 

Title : between tradition and modern medicine: the ethical challenges facing Africa  

In Africa as in other continents, health remains a major concern. If being healthy means being mentally and physically sound, it should also be highlighted that good manners are necessary when dealing with people’s health; otherwise the target set might not be reached. When administering healthcare, the conditions that should be met, as concerns the topic we are discussing, are ethical. We will, in the lines below, ponder over the relationship between ethics and health in Africa.  In order to discuss this interesting and itching issue we would like to focus on a rather original questioning of our theme. What are the ethical challenges for health in an African continent faced with the burden of tradition and the rational pressures of modern medicine? We will firstly talk about the African conception of illness and the drawbacks of medical progress. We will recall some distressing facts in order to excavate some ethical principles. These principles are not always obeyed. They are sometimes bypassed. That is the reason why we shall end our reflection with some proposals and an example. 

 

ILLNESS AND CULTURE

 

The understanding of physical or mental illness, its causes and its cures, is sometimes conditioned by cultures. The cultural context is important for medical care, and the treatment of diseases must first abide by the laws of science and take culture into consideration if it is to be efficient and satisfactory. It is worth mentioning that every individual lives in a specific cultural context.

 Culture is all about the lifestyle of a group deeply rooted in the way they adapt to a given environment, it is their vision of the world; similar ways of thinking, acting and doing, similar attitudes, aspirations and practices.

In western civilisation where science and individualism prevail, good health is understood as the absence of diseases, particularly the absence of germs and viruses. That is why medical care is based on evidence and a kind of objectivity that hardly considers the culture of the patient. In African tradition where community spirits and parental links prevail, health is a much more complex issue and the recovery from an illness or a spell is more than a simple technical elimination of a plague or an affliction.

There have been tremendous headways in medical science and medicine has remarkably evolved in the last fifty years. It now appears as the evolution of an art linked to a culture, to a global science. There is, for example, aesthetical surgery thanks to which several people can get rid of physical impairments. We could also mention the victory over some terrible diseases like tuberculosis. This improvement on the well being of humans brings about a longer life expectancy in African countries and the world. This is reinforced by the discovery of many vaccines and their availability in African countries. It could be mentioned that this was possible thanks to industrial and commercial revolution and thanks to science and technology.

 

DRAWBACKS OF MEDICAL PROGRESS : THE PROBLEMS FACING AFRICA

 

We would like to emphasise that despite medical progress, the African continent is still lagging behind. There are many causes to explain this: improper medical practices, the uneven distribution of available medical resources in the world; the outbreak and the spread of deadlier epidemics and diseases; the negative role of trade monopoly, intensive business activities and the surge in profit, the failure to compensate traditional health systems. There is imbalance between the available funds for health research in Africa and the diseases responsible for greater mortality.

The disease burden has become a prime indicator to assess health, reforms, developmental policies, planning, the distribution of resources and so on. Traditionally, the disease burden was assessed on the basis of epidemiological methods and statistics upon morbidity and mortality. Some criteria can be used to quantify the disease burden, namely:  the impact of premature deaths and incapacities.  The assessment of the future of specific sanitary interventions. Whatever the criterion used, the burden of the world morbidity heavily cripples developing countries, particularly in Sub Saharan Africa. Let us discuss the situation in some of these countries.

-Immunization

The mortality rate for children and mothers is still high in Africa. More Immunization campaigns should be organised in order to bring it down. This is true for diseases such as tetanus, diphtheria, meningitis, TB, poliomyelitis, whopping cough, measles, yellow fever, and hepatitis B. parents either neglect to respect the immunization schedule or they start and fail to complete. Immunization is ineffective if it is Incomplete. In Africa these diseases often lead to the death of the child before he/she is one year old.  A child who is not vaccinated against poliomyelitis might be crippled for the rest of his/her life.

Also linked to vaccination is the issue of imbalanced diet. The lack of vitamin A for instance, leads to the death of approximately I0 600 children in Cameroon each year. To tackle this problem, the government of Ivory Coast decided to set up the AYAME children’s home in the South West of Ivory Coast. It is henceforth of utmost importance for the pregnant woman  and for the child to have a healthy or balanced diet

 

-AIDS:as concerns this disease, it is obvious that patients do not easily adhere to anti retro viral treatment. More sensitization campaigns should be organised. Besides, people find it economically difficult to have access to drugs that can combat AIDS. Apart from South Africa which has been allowed to manufacture Anti retro viral drugs, the other African countries are faced with the shortage of drugs, and many people die because of this.

 

In Cameroon, for instance, the health personnel sometimes misappropriates the ARV destined to patients in order to sell at a higher price, thus penalising AIDS patients. Pr Victor Anomah Ngu, former minister of Public Health in Cameroon is about to complete a treatment against this disease: Vanhivax (Victor Anomah NGU HIV Vaccine), he now needs about two thousand million to move forward in his research. This vaccine has proven its effectiveness as it has helped many people to recover after having been treated with it. Professor ANOMAH NGU is sure that his discovery will be an appropriate solution. 18 people have been cured by the vaccine of this 82 year old professor.

 

-Malaria: Malaria is a great killer in Africa. In the Far North Region of Cameroon, 183 941 cases of malaria were recorded in 2007 only. 960 deaths were officially recorded.  Many die because they take drugs to which the parasite has become stubbornly resistant. Many patients cannot have access to more effective new medicines such as: Artesunates, Amodiaquin, and Arthemeter-Lumefantrin. The reason is that all health centres are not provided with them because they are remote from regional headquarters. 

There are some preventive steps that are taken to make the fight more effective. One can name the distribution of impregnated mosquito nets among others.

 

Blood Transfusion : It is worth mentioning that blood donations to save the lives of those who suffer from anaemia are rarer and rarer ; according to the WHO, only 39% of the 80 million blood units that are collected all over the world come from developing countries whereas they represent 82% of the population of the world. Every country should take measures to overcome this shortage and the hazards linked to blood transfusion like the contamination of certain diseases, etc.  This is an emergency since 5% of HIV AIDS Infection is caused by blood transfusion.

Other miscellaneous problems :

As other parts of the world, Africa is hit by climatic changes. These changes not only bring about some modifications in the ecosystem but also give birth to new germs that represent a threat to humans. It is hence obvious that micro organisms are sensitive to global changes although the way they will react is still a mystery.

Smoking:  40% of students smoke in Cameroon. Such figures should be causes for alarm. Youth are at risk of catching cardiovascular diseases and cancer.

 

Other alarming facts

Contagious diseases, malnutrition, paediatric diseases, maternal and prenatal problems and epidemics are still a major concern for health care in Africa. 

Despite a considerable reduction of infant mortality, the rate is still 20 times higher than in developed countries. Despite another significant reduction in maternal morbidity/mortality the number of African women who die because of problems linked to pregnancy is still 100 times higher than in developed countries.

 Life expectancy has increased in the last two decades; yet it is still shorter than in industrialised countries. In addition, it is dwindling again due to current epidemics, wars, genocidal killings and other happenings which jeopardise health and life.

According to UN sources, 90% of 300 million cases of severe malaria leading to a millionth death each year, mainly of children under the age of 5, are recorded in Africa. By 2025, over 80 million Africans might die of AIDS and about 90 million people will be suffering from TB.

Sub Saharan Africa represents about 10%of the world’s population. At the end of 2006, approximately 39, 5 million people were living with HIV/AIDS in the world, 63% of whom were found in Sub Saharan Africa. Africa has one of the highest rates of HIV spread in the world. Of 4.3 million new infections in 2006, 2.8 were in Africa. Still in 2006, 2.1 people died of AIDS. This represented 72% of all deaths linked to AIDS in the world.  

In most African countries, the percentage of the budget devoted to health it low: less than 10%. The majority of AIDS control programmes are supported by foreign funds. Whenever this support dries up many initiatives to counter AIDS are hindered. This has for instance been the case of screening tests. The earnings of AIDS patients dwindle because of their ill health. They thus permanently need permanent support in order to have at least the subsistence revenue that may help them to minimise worries that can worsen their situation. 

Of 1450 new drugs sold in Africa between 1972 and 1997, only 13 could fight tropical diseases. It is the pharmaceutical industry itself that shortlists, sponsors and manages these studies. The choice of drugs and their appraisal are systematically biased. On one side, laboratories want a return on their investments, on the other side, local authorities find it hard to conceive an unequivocal and coherent drug policy which can enable them to better control the work of laboratories.

The dichotomy between scientific interest and commercial dividend is exacerbated in underdeveloped countries because of the wide gap that exists between the industrial requirements of the drug and the poverty of southern nations. At the end of the 1990s, the turnover of the pharmaceutical industry in the world (€ 380 thousand million) was higher than the Gross National Product of Sub Saharan countries (€ 300 thousand million).

There are many reasons for this: the overwhelming poverty of Africa, the high number of opportunistic infections due to HIV/AIDS patients : TB, typhoid, meningitis, Burili ulcer, etc. modern health facilities/infrastructure are few ; the illiteracy rate is high, the available data are patchy ; the lack of transportation  and/or communication means in case of emergency, the absence of a political will, political instability (there is currently an epidemics of  cholera in Zimbabwe), armed conflicts, civil wars, backward habits, hazardous health practices, and despair;

Having said this, we can now discuss the question of ethics in the domain of health in Africa. Ethics here actually means bioethics as it is related to life.

ETHICAL PRINCIPLES

Bioethical principles as well moral ones are universal. Their relevance and validity transcends cultures. They have a special status that rationally makes them more compelling and imposing than laws, customs, traditions and social practices. Ethical norms and rules that derive from universal ethical principles can be recognised and distinguished from unethical rules and norms by an implicit ethical necessity. These rules are however not hard and fast. They can be sensibly violated under certain clear circumstances if need be. Moreover, to be applied in a given context, they need to be adapted to the form, the colour and the scope of the context.

Any medical study or intervention in which humans are involved must be conducted in abidance by four essential ethical principles:  the respect for the human being, beneficial action, harmlessness and equity.  A conscientious preparation for scientific projects should take these principles into account. According to circumstances, the expression of principles and the value attached to them may differ and their sound implementation could have various consequences and lead to dissimilar decisions or actions.

The respect for the individual inbioethics or health ethics encapsulates two basic ethical notions: 1- the autonomy: every -one who is able to set their own objective should be considered with the respect due to their self determination capacity. The protection of the people whose autonomy is breached or diminished requires that people under dependency or those who are vulnerable be protected against any abuses or prejudice.

The beneficial action is the obligation for every ethical theory to maximise individual advantages and to minimise the possibility to be a nuisance or to commit mistakes. Norms which derive from these principles require that research hazards be reasonable with regards to expected gains. Such research should be well conceived and researchers should have the necessary qualifications to carry out the work as well as to respect the integrity of humans on whom this research is conducted.   

The notion of harmlessness which also means « not to hurt » is a key principle of traditional medical ethics. The aim is to protect the individual who is being taken care of from any harmful action. 

The notion of equity requires that all similar cases be given equal consideration and dissimilar cases be given an attention which takes their divergence into account. Applied to people under dependency or vulnerable ones, this principle rests on rules of distributive law. Distributive law applies within a community and among communities. Paupers should not bear a disproportioned share of the burden of a treatment if all the members will benefit from it. This applies to research on AIDS for example. Are these principles respected in Africa?

EXAMPLES OF CASES WHEN ETHICAL PRINCIPLES ARE VIOLATED

In Africa, medical and pharmaceutical rules are those of the colonial era and seem obsolete or outdated. Hazards linked to the non respect of these ethical principles are so high that more laboratories tend to conduct their guinea pig experiment in the African continent. In fact the cost is five times lower than in developed countries. Furthermore, epidemiological conditions in Africa seem to be more suitable to the realisation of tests: higher frequency of diseases, particularly those which are infectious, and the existence of symptoms yet to be weakened by repeated and intensive healthcare. Finally, it is easy to convince patients in utmost despair because of the poor coverage of health facilities.

In such a context, it is easy to bypass ethical principles. In Nigeria, for instance, when carrying out the clinical tests of the Trovan ®, (a vaccine) neither the Nigerian authorities nor the ethics committee were officially consulted on how to inform the families and obtain their consent. Similarly, from July 2004 to January 2005 when testing Tenofovir ®, an antiviral drug, on about 400 Cameroonian sex workers, ethical principles were violated.  This molecule reduces the transmission of the Ape Immunodeficiency Virus, the equivalent of HIV in Apes. The manufacturer wanted to test its effectiveness on Humans and sampled people with risky lifestyles: the prostitutes from countries with a high infection rate since the probability to contract AIDs there was high as well. Many of the sampled sex workers could not read documents in English and thought that they were being vaccinated. It is most often the duty of ethics committee as recommended by the World Medical Association in their 1964 Helsinki declaration to examine the experimentation procedures before the testing; to check their relevance and their applicability in the social and economic context of the area where the study will be conducted. We could mention here that in the last ten years these committees have progressively being put in place in Africa even though they are yet to be provided with the required competence and means. 

Some flaws

The clinical testing of the Trovan ® could be justified since it was necessary to test itseffectiveness on an great number of patients, that is, 200 children in Nigeria. However those who were carrying the test felt concerned neither about the cost of the drug nor about the possibilities for its sales in the absence of any social security agreement to pay medical expenses or to reimburse expenses incurred, and hence of the virtual impossibility to use the drug in Africa. This was a serious violation of the ethical code.  

As concerns the tests administered in Cameroon, there seems to have been no concerns on the relevance of Tenofovir ® in Africa. In fact, if the clinical testing proves that the HIV transmission can be blocked by the Tenofovir ®, this medicine will be proposed as prophylactic treatment against AIDS. Is such a target reachable in a continent where the treatment of patients and the availability of cheap condoms already face so many hindrances? The question deserved to be asked since the experience of prophylactic treatment against malaria has shown that it is a utopia to think that one could spend huge amount of money to buy an expensive treatment, especially if one knows that one is in sound health.  That could be the reason why some people believed that clinical testing was administered in southern states, particularly on prostitutes because it was an easy and cheap way to have a fast and conclusive proof of its effectiveness.  Is this not anotherviolation of ethical principles?

One has the impression that strategic imperialism is being put in place in order to impose specific rules upon the poor without asking for their consent. One would hardly agree with Mr Philippe Kourilsky, the General Manager of the Pasteur Institute of Paris who asserted that a sort of ideological imperialism was being put in place in order to spread rules that only apply to the wealthy to those who cannot assume them.  Those who set rules are not well placed to indicate who can assume them or not. Not long ago, pertinent reactions were recorded from people who asserted that what had taken place in Nigeria as concerns the DT Polio vaccine should not be repeated. The Cameroonian minister of health, André Mama Fouda, declared that in Cameroon a combined injectable vaccine had been homologated since 2006 under the appellation DultavaxR.  That vaccine is not sponsored by any health programmes.

In France, the pharmaceutical firm, SANOFI Pasteur MSD, decided to call off the distribution of the DT POLIO vaccine and to bring the remaining stocks back to their laboratories because of the numerous cases of allergy in children vaccinated from the beginning of the year 2008 onwards. The worse was avoided thanks to these two measures.

PROPOSALS

It would seem necessary for Africans themselvesto master how to administer clinical testingin order to addressspecific public healthneeds in the continent. This issue seems to be of utmost importance as the tests could also be carried out on traditional medicines which are cheaper and likely to be more accepted by the population. The clinical testing could prove the harmlessness and the efficiency of medicines that can valorise the national assets. This could lead to the emergence of a home pharmaceutical business. The African plants which are anti infectious, anti inflammatory or diuretic, could be used against infections, rheumatisms, hypertension or heart condition and line up behind the now famous example of quinine made from quinquina.

Medicines tested in Africa should correspond to the needs of the continents. They should go along with specific criteria determined by their future use: effectiveness and harmlessness in relation to the inadequate local chemical watch, easy use of the drug (easy to prescribe, to consume and to store). All this will ease the distribution and the adhesion of patients to the treatment; hence solving the flaws of the health system. The drugs will be more available. Most importantly, there is need to boost the capacity of the local authorities to make decisions, achieve and keep an eagle eye on the health system in order to make it possible to enjoy full independence as far as clinical studies are concerned.

In African countries, legal texts governing health sectors are either non existent or not enforced. It is time such a loopholewas closed. Theseprofessions are insufficientlyprovided with regulatory texts as concerns the precise conception of properethical or deontological texts. Besides, these countries don’t have a customary tradition that could make up for the absence of such texts. A sound and relevant juridical framework is henceforth necessary if these problems are to be tackled. This framework should take all the aspects into account, the definition of ethical and deontological norms should be included therewith. It should be drafted through a participatory approach. It should, above all, be based on rules to be promoted; the text should be made into a law, not a simple regulatory by-law.

 

 

AN  EXEMPLE OF  MEDICAL ASSISTANCE

Javier Lozano Cardinal Barragan had this to say : « in Africa… the church implements religious educational programmes to train social, religious and health workers to sensitize the populations , give humanitarian assistance to sick people at home and in hospitals. » He went on saying that “we fight against stigmatization, we facilitate diagnostics, counselling and reconciliation. We provide antiretroviral drugs, medicines to prevent mother to child transmission”. The Dominican health Centre (CHD) Saint Martin de Porres in  Yaoundé, Cameroon, managed by Sister Christine medical doctor, is an example of the implementation of these actions as it is among the 27% of catholic health centres in the world which give health care to AIDS patients and others.

Apart from the 120 sick people who are daily taken care of, the CHD provides its personnel, youth, families, and sick people with quality training. As soon as people become aware that they are HIV positive theydevelop identity breaches which installgaps in their capacities to connectwith others. The HIV positive patient should face the psycho social difficulties linked to his or her health status. At this level the CHD helps them to better understand their new status and to shoulder the new condition by accepting to undergo the antiviral treatment and committing themselves to lead a positive existence that is, without considering the situation as desperate. The CHD focuses its pastoral of health on the Good Samaritan gospel (Luke 10, 20). This text highlights the paradigm of merciful love which goes beyond human barriers.  

Father TOKO Jean Bernard, Dominican Priest

tjblefils@yahoo.fr

00 237 75372058

CAMEROON