Difference between revisions of "Health in Zaire"

Latest revision as of 03:00, 26 December 2006

Zairian health statistics are similar to those of other countries in Central Africa. Life expectancy at birth in 1992 was estimated at fifty-two years for males and fifty-six years for females. While unimpressive by United States standards, the statistics on life expectancy have improved markedly, a real achievement given the challenges to public health the country faces.

Incidence of Disease

Infectious and parasitic diseases are a major health threat, accounting for at least 50 percent of all deaths in Zaire. (The United States rate, by comparison, is 1.5 percent.) Malaria, trypanosomiasis (sleeping sickness), onchocerciasis (river blindness), and schistosomiasis are all endemic. Malaria, long a significant cause of illness and death, is increasingly menacing because of its growing resistance to antimalarial drugs. Cases of trypanosomiasis are increasing, primarily because of a reduction in the number of mobile teams engaged in controlling the spread of the vector, the tsetse fly. Diseases such as measles, diarrheal diseases, tetanus, diphtheria, pertussis, poliomyelitis, tuberculosis, and leprosy are preventable or curable given available technology; unfortunately, only 30 to 40 percent of the population has access to such technology and services. The UN has estimated the immunization rate in the early 1990s to be only 38 percent for measles and 35 percent for diphtheria, pertussis, and tetanus. In addition, a majority of the population is infected with intestinal worms, including ascaris, hookworms, and ankylostomes; the effect of these parasites is to further weaken a population already suffering from widespread malnutrition.

The disease burden has fallen particularly heavily on children under the age of five. They constitute roughly 20 percent of the population and account for 80 percent of all deaths. Malaria is the primary killer among infants, while measles, malaria, and diarrheal diseases are responsible for the bulk of deaths of children under five.

Acquired immune deficiency syndrome (AIDS) and other sexually transmitted diseases have been spreading rapidly. As of 1990, the number of reported cases in Zaire totaled 11,732, a 60 percent increase over 1989. In urban areas, the AIDS epidemic is the most threatening public-health problem facing the nation. Seropositivity statistics (the proportion of a population whose blood serum tests positive for the AIDS virus) in Kinshasa for the general population in 1987 were 6 to 8 percent; among prostitutes the figure was as high as 30 percent. The scanty data from rural areas show a lower incidence, but the samples are too small to be statistically significant.

AIDS is regarded as a potentially even greater public-health hazard in the face of the virtual collapse of the state-run health care system. By most accounts, in 1993 the majority of blood banks had been closed, and blood screenings were rare.

AIDS transmission in Zaire occurs primarily through sexual, mostly heterosexual, intercourse (80 percent); infected blood transfusions and contaminated skin-piercing instruments account for 15 percent of cases, and transmission from infected mothers to their offspring for 5 percent. The significance of heterosexual intercourse in the spread of the disease is documented in the ratio of afflicted men to afflicted women; in Zaire it is 1:1.4, while in the United States it is 13:1.

Initial public reaction to the early warnings sounded by the medical authorities tended to be skeptical. In a play on the French acronym for AIDS, SIDA (syndrome immunité déficient acquis), Kinshasa street slang labeled the new disease the "syndrome inventé pour décourager les amoureux," or, crudely translated, "syndrome invented to discourage lovers." But as increasing numbers of well-known musicians and other public figures have contracted the disease and died, public attitudes have grown more sober. Public health authorities have attempted to promote safe-sex education in their health education programs. In addition, the United States Agency for International Development (AID) funded AIDS research programs and health education programs through Project SIDA, and the government used a US$500,000 grant from the World Health Organization, together with money from other international agencies, to establish a national AIDS control program. Thus far, however, success in slowing the spread of the epidemic remains elusive, and rates of prophylactic use remain low.

Health Care System

In a regional context, the health care system established to meet these challenges appears impressive, at least on paper, although the UN estimates that only 50 percent of the population had access to health care in the early 1990s. The ratio of physicians to population in the early 1990s was claimed to be approximately one per 14,000, markedly higher than in neighboring countries such as Rwanda (one to 35,000) or Burundi (one to 45,000), for example. The ratio of nurses to population was estimated as approximately one to 1,900, spectacularly higher than the sub-Saharan African average of one to 45,000. Average population per hospital bed was approximately 700, a better rate than neighboring Burundi's 850, for example.

In theory, the nation is divided into health zones, each covering a population of 100,000 to 150,000 and containing on average one referral hospital, between one and three reference health centers, and fifteen to twenty-five standard health centers. Each standard health center is staffed with at least one certified nurse and provides basic preventive and simple curative services to the five to ten villages in its area. Serious medical cases are referred upward to the health zone's reference health centers and referral hospital.

The health care system is considerably less impressive in practice, however. The relatively high physician- and paramedic-to- population ratio masks the fact that the quality of medical education has seriously deteriorated. Moreover, salaries of medical personnel are too low to permit staff the luxury of full-time attention to their professional duties. Virtually all people employed in the public sector must seek outside income in order to survive. It is not uncommon for state hospital nurses, for example, to demand private payment from a hospitalized patient or the patient's family before changing a dressing, or before administering a medication prescribed by the patient's physician. In fact, according to Janet MacGaffey, doctors, nurses, and other medical personnel routinely require payment of a personal fee before they will care for a patient. Even emergency cases are not admitted to a hospital until payment has been made.

The large number of health centers and health zones cited in statistics is similarly misleading. Many government health centers are dysfunctional, completely lacking in medications or in basic medical equipment and personnel. In the early 1990s, the publichealth system had deteriorated further as a result of civil and political unrest and severe economic disruptions. Indeed, the government's health services have in essence collapsed. What health care Zairians find comes more often private sources. The elite continue to seek quality health care abroad.

Religious organizations, notably the Roman Catholic, Protestant, and Kimbanguist churches, and international relief organizations provide the bulk of health care in Zaire, particularly in rural areas, as happened in the preindependence era as well. The Catholic medical service network is the largest and involves primary responsibility for some ninety health zones. The Protestant network participates in the development of fifty health zones; as the implementing agent of an AID-supported rural health project, it plans to develop fifty more health zones over a sevenyear period. Kimbanguist medical work centers on the rehabilitation of two urban hospitals and on management of 180 health centers scattered all over the country. Private enterprises also manage large health care facilities where they provide high-quality care. The large parastatal General Quarries and Mines (Générale des Carrières et des Mines--Gécamines), for example, owns seven hospitals and six clinics with about 2,264 beds.

Sanitation and Nutrition

According to UN estimates, only 14 percent of the population has access to safe water (52 percent urban and 20 percent rural). Potable water is provided to approximately half the population in urban areas through private connections or through public standpipes. The remaining 50 percent get their water from wells and surface water of varying quality. Roughly 30 percent of the urban population has access to a sewage system, 10 percent use septic tanks, and 60 percent use latrines. There is no garbage collection system. In rural areas, water quality varies widely. Only about 10 percent of the rural population has access to communal standpipes. About 20 percent of the population uses pit latrines.

Malnutrition is widespread in Zaire. Measures of children's standard weight-for-age show at least 25 percent of the country's children to be undernourished. Protein-calorie malnutrition and anemia are widespread. Iodine-deficiency disorders resulting in the growth of goiters and in cretinism are commonly seen in Équateur and in Haut-Zaïre.

The major cause of malnutrition is poverty. Gross domestic product per capita has been decreasing in the 1980s and early 1990s, and Zaire's per capita GDP places Zaire among the poorest and least-developed countries in the world. Local markets are reported to have abundant supplies of food, but most of the population cannot afford to buy it. For example, average earnings in the capital of Kinshasa are not enough to buy the minimum basket of essential foods. Deficiencies in food production and diet are additional causes of malnutrition. Food and Agriculture Organization of the United Nations (FAO) statistics show national average calorie production per inhabitant as less than the minimum daily consumption requirements. The balance is made up by importing food. Dependency on cassava as a staple further degrades the diet. Cassava contains few nutrients, and the cyanide it contains is not always properly leached out in the process of food preparation.

Family Planning

Family planning began late and was accepted slowly in Zaire. In 1972 the Mobutu regime officially expressed interest in limiting births to "desirable" ones and thus promoted family planning for reasons of health and as a human right. In 1973 a presidential decree created an official clearinghouse committee for familyplanning information. It was not until 1978, however, that the state established a nongovernment organization dedicated to family planning, namely the Zairian Association for Family Well-Being (Association Zaïroise pour le Bien- Être Familial--AZBEF). It was formed in order to acquire technical and financial aid from the International Planned Parenthood Federation. Evaluation teams sent in 1981 were unable to evaluate the impact of the early programs because of the lack of data and the small numbers of acceptors.

Not until the launching of an AID-funded program in 1982--the Project for Planned Birth Services (Projet des Services des Naissances Désirables--PSND)--did family-planning efforts begin in earnest. Problems in coordinating PSND efforts with AZBEF led to the establishment of three systems working in parallel, PSND, AZBEF, and Rural Health (Santé Rurale--Sanru), a rural family health care project with a family-planning component.

PSND statistics have been the most complete. PSND selected fourteen urban areas with a target population of about 800,000 women and aimed to increase contraceptive use from 1 percent to 12 percent by 1986. Early returns were disappointing, with only 1.6 percent usage reported by a mid-term evaluation mission in 1985. Later trends were more encouraging, including a 1984-87 quadrupling of family-planning acceptors.

In rural areas, AZBEF family-planning units and Sanru have been active, although the numbers of personnel were insufficient to reach the bulk of the population. To supplement their efforts, AID funded efforts to make contraceptives available through communitybased distribution projects. A Tulane University program distributed birth-control pills, condoms, and contraceptive foams in Bas-Zaïre in a pilot project; the effort demonstrated that such distribution was less effective than making supplies available in health facilities. Companies such as Gécamines that operated health care facilities received aid from PSND to promote family planning among company workers and their families. Most significant were commercial marketing projects. Forty pharmacies in three zones of Kinshasa spread information on contraceptive methods and products and sold attractively packaged and well-priced contraceptives, which were quite popular. Recent efforts in social marketing organized by Family Health International have had promising results in their test areas, although the collapse of the economy in the early 1990s has compromised any precise evaluation of their overall effectiveness.

Barriers to acceptance of family planning remain, however. As long as child mortality remains high, both men and women will continue to value large families. Demand for family-planning services remains low. In fact, the availability of such services has been almost unknown by the community, even in the immediate neighborhood of family-planning units. Although occasional radio, television, and press programs have been generated, and T-shirts, posters, and brochures bearing family-planning messages have been distributed, follow-up has been lacking and evaluation of familyplanning informational campaigns has not been done. Given the relative lack of success in promoting family planning and birth control, Zaire faces a continued high rate of population growth, which will exacerbate deteriorating social and economic conditions.

Note: This article comes from Zaire: A Country Study, which is in the public domain. Full credit goes to the authors of it.