Examination of Witnesses (Questions 23
- 39)
TUESDAY 16 OCTOBER 2007
DR GRACE
KODINDO
Q23 Chairman: Thank you very much,
Grace Kodindo, for coming in. Some of us did have an opportunity
to see the first part, we did not see all of it, of the Panorama
film of Chad in which you very much featured. I can say that I
think it was powerful and moving, but also shocking in particular
to me that people were not only required to pay but literally
had to go and find the drugs while a woman was potentially dying
under your care. That that sort of situation and that sort of
trauma should exist I think is something which is important that
we are aware of. I am very grateful and we are very grateful to
you for coming to give us your personal testimony, if you like,
about the challenges that you face and, of course, about the extraordinary
good work you do in very, very challenging circumstances. I just
wondered if, by way of introduction, you could give us some feel
for the challenges you do face. In particular, our understanding
is that one out of 11 women in Chad will die as a result of complications
of pregnancy; that Chadian women have on average 6.7 children,
which I think people in this country would find fairly stark,
and yet only 25% of them get any kind of trained assistance during
childbirth and much lower in rural areas. What do you see from
your experience drives the high mortality rate that your country
suffers? You heard the previous discussion about poverty, ignorance,
lack of knowledge and the lack of skills and the supplies within
the infrastructure; but from your personal experience what do
you think is the central problem driving this; what do you think
are the key areas which are causing this very high and tragic
mortality rate?
Dr Kodindo: Firstly, I would like
to thank you on behalf not only of women from Chad but women from
all developing countries, especially ones from sub-Saharan Africa,
from South Asia and also Latin America. I would like to thank
you for the opportunity to hear our voices and, hopefully, to
help our country to take action to improve our health. I would
like to introduce myself. My name is Grace Kodindo. I am an obstetrician
and gynaecologist. I have been working for the last 30 years in
Chad first as a general practitioner, and then as an obstetrician
and gynaecologist. Indeed, at the same time as I was working in
Chad, I was also working for Columbia University as a monitor
to implement emergency obstetric care. For the last six months
I have also been working, again for Columbia University, in a
programme called RAISE,[11]
to improve the access to reproductive health for women refugees.
What are the causes of maternal deaths in our countries? I would
like to say that in our countries, just like the situation was
in Europe, in North America, one or two centuries before, people
die from the same causes you had here in Europe. In the 30s you
started to have technology like Caesarean section, anaesthesia,
blood transfusion; and then in the 40s you discovered antibiotics
and then contraceptive methods, and then you started to make this
available to all women everywhere; even the poorest of women in
the West now can have access to them. That is not the situation
in our country. So we need this kind of basic care with appropriately
trained staff to be available to all women in our countries and
we will come to the same result that you have reached here in
Europe and in America. The problem is for that we need a stronger
health system. My colleagues before me have said the same thing,
because only a strong system can really provide all the basic
drugs, even a drug that is cheap in the West like magnesium sulphate.
This is the drug to treat eclampsia. You would not believe that
it is still not on the list of essential drugs in many African
countries—not only in Chad; I have seen that in Cameroon,
in Nigeria, in Ethiopia. Two weeks ago I was in the Congo and
they do not have that and this is a cheap drug, and this is the
one drug that can treat eclampsia which is one of the main causes
of maternal death in our countries. In many of these places that
I have visited they do not have a functioning health system; they
do not have a blood bank or anything like that. Haemorrhage is
one of the first causes of maternal death; when a woman is bleeding
it will only take two hours and she may die from that. When there
is no blood to transfuse her she will die. If a woman is living
in a very rural area, in remote places, with no transportation,
sometimes the relatives have to take them on their shoulders and
walk two or three days before reaching a health facility. She
may die in the meantime, or if she does not die the baby will
die. If she survives she will end up with a fistula. You had fistula
in the West in the past. The first fistula hospital was in New
York but it has been closed because you have produced care to
all women everywhere but we still do not have that in our countries.
If there is no action taken on that we still have a long way ahead
of us. For a woman to end up with a fistula, and if you know what
a fistula is—it is a hole in the vagina that produces a
leakage of urine or faeces continually for the woman, and the
woman smells so bad that sometimes the husband just leaves them,
and their families just leave them and they are left as social
outcasts. You still have a lot of these cases in Chad, Nigeria,
in Sudan and Ethiopia even in 2007. The same problems are still
there because we do not have a strong enough health system. In
the film you have a 12-year old girl dying from an unsafe abortion
because the access to family planning is still a luxury in many
of our countries, especially in the rural area. In cities a woman
may have access to family planning, but in rural areas it does
not exist and it is not only in Chad. In June I was in Ethiopia,
I went to the Tigray region and in the rural area they do not
have that; no EmOC;[12]
no family planning, and this is how the West has reduced maternal
mortality. In the West we have maybe one woman out of 47,000 dying,
whereas in Chad we have one out of 11. In Mali we have one out
of 10. In Sierra Leone, in Afghanistan, we have one out of eight.
You can see the difference. It is basic technology. It is not
something complicated—I am talking about blood transfusions,
Caesarean sections, some drugs like magnesium sulphate, only basic
things that you have plenty of here in the West.
Q24 Chairman: What comes across loud
and clear is that, as you put it and our previous witnesses put
it, you need a functioning health service and more resources.
In a sense it is a silly question but it is the huge number of
resources across so many countries, and taking your own country,
and given your professional qualifications, skill and experience,
if you were to identify one particular thing from your standpoint
that would most advance the cause, what would it be, or is that
a naïve question?
Dr Kodindo: We need to increase
our skills as providers and to increase the coverage of the work
on this, especially in the remote areas, the rural areas. These
kinds of people we really need to give them a very large widespread
coverage of these basic things. We can take one health centre
in a rural area with just a nurse; we do not need a doctor or
a specialist. This example has been done in Burkina Faso, a nurse
with two years' training in obstetric skills can be posted there
with a few drugs, only antibiotics, IV[13]
fluids and magnesium sulphate, to give the first basic treatment
when there is any complication and then to help in referral. This
is another problem, the referral system in Africa. It is not only
a shortage of the skill provided but the referral system. This
is why maternal mortality prevention will not only be a problem
for the Minister of Health, it is a multidisciplinary problem.
The Minister of Finance should help to give some incentives. The
thing is these are very, very poor countries and the salaries
are very low and as human beings these people need to have some
incentive to be retained. Many African staff have immigrated but
if you can train this medical provider and give them some incentive
they will return. They need a medical environment and need to
have some incentive because they have lots of families to raise.
If they have that in these areas and you have roads, and means
of transportation to take them to the referral hospital, and also
have drugs and blood banks functioning, it should be functioning.
As you have seen in my film that hospital is the referral hospital
for the country and we have no blood bank functioning. Even syringes
are needed, you would not believe it, there is nothing there.
Syringes, needle catheter, they have to go outside to buy that.
This is encouraging the nurses or doctors to start to steal things
and go and buy them because if the hospital has nothing they will
just steal and do some business with that. It is not helping the
honesty in these places. The hospital really has nothing to help
save a woman's life, women continue to die. The solution is very
simple, just like you have proven in the West: in many countries
in Asia and Africa which are doing well, as Dr Songane was saying,
it is because they have strengthened the health system and they
have also improved the access. The health system may increase
but if the access is not there it will not happen. There are many
problems with access. It is not only the lack of roads, but the
financial access and the cultural access. Like in Chad, more than
80 % of women are illiterate so they cannot even make decisions
for themselves. They need to be educated to improve their utilisation
of the health service that will be strengthened, hopefully, in
the future. I will give you one example that happened in Senegal.
They have given some training for a literacy course to women in
rural areas and they have trained them to recognise that they
have their own right to defend. They did not even know they had
a right to talk about whether to say yes or no. After that training
without anyone telling them to come back, they came back in the
morning and said, "Now we know that we can talk about our
health we are going to put an end to female genital mutilation".
That was only one literacy course. They have learnt that they
have their own rights. They need to be educated. One other problem
in our country is the condition of the woman. There is a very
low status for women. The woman is good for being married and
having children and that is all. She should have as many children
as God gives. There is no limit. She does not even have a choice
to limit the children. She has as many as God will give her. If
she dies in the meantime they will say that God has also brought
the death. Nobody will be shocked by that. All this is related
to the condition of women. Maternal mortality prevention should
be something multi-disciplinary, multi-sectoral, and should not
only be the problem of the Minister of Health. They are not able
enough to put an end to that.
Q25 Richard Burden: Can we explore
the issue of access to basic medicines. You mentioned particularly
about magnesium sulphate as being very effective in eclampsia.
Objectively magnesium sulphate should not be difficult to get
hold of; it should not be very expensive.
Dr Kodindo: It is very cheap.
Q26 Richard Burden: It is very effective.
Dr Kodindo: Yes.
Q27 Richard Burden: Given the incidence
of eclampsia in Chad what needs to happen to make sure, for example,
that magnesium sulphate could be freely available; and what internationally
do we need to do to try to make sure that happens? You may want
to expand to other basic medicines, but that one just seems quite
a simple one but just is not happening. What do we need to do
to make it happen?
Dr Kodindo: Firstly, accordingly
to WHO this is the most effective drug for eclampsia. I think
it should be included in the list of essential reproductive health
drugs in all countries. It should be put in the political programme
for reproductive health. The governments should start to import
them. Until now even in sub-Saharan countries it is not even on
the list of essential drugs in the countries, so they are not
buying them, and these are very cheap drugs here.
Q28 Ann McKechin: Can I just clarify,
that is the individual list of the Chadian Government; or is this
a universal list of central drugs? Is this the Chadian Government's
decision about what essential drugs are?
Dr Kodindo: No, this is from WHO.
WHO has a list of essential drugs.
Q29 Chairman: It is not on the WHO
list?
Dr Kodindo: That is recommended
as the best drug for eclampsia. It should be on the list of each
country. It is not on the international list of essential drugs,
and this should be on the list so that the Government can start
to import the drugs.
Q30 Hugh Bayley: Is it possible to
put an economic cost on what it would cost to ensure a safe childbirth
environment for a child in a developing country; and then run
a global campaign and say, in the same way there should be universal
medication at $200 per person for anybody with HIV, there should
be a global campaign and there should be $10 or $20, whatever
it costs, per child to be used in the health system? Who could
give us that information?
Dr Kodindo: There is the Taskforce
on MDG 5. My colleague Lynn Freedman is working on the Taskforce
for MDG 5, and she has said that £4.5 billion per year could
provide all effective intervention for maternal and newborn cases
to 95 % of the world's population.
Q31 Hugh Bayley: How many births
are there per year globally?
Dr Kodindo: 136 million.[14]
Q32 Sir Robert Smith: You were talking
about some of the solutions in rural areas and highlighting also
how skilled intervention makes a huge difference to outcomes.
I just wondered in terms of priority and stepping stones to try
to improve the situation, is it mobile health workers, or is it
training the local midwives, or even at a more basic level is
it improving the transport so that the pregnant woman can get
to a more major centre?
Dr Kodindo: Yes, I think that
in a rural area we should start with some basic medical care,
so that we do not need to have even a fully trained midwife; you
can train mid level providers. In the health centre it should
be nurses only. They should be provided with a few basic supplies
and drugs; and they should be connected with the hospital where
the mid level surgical technician, just like Mozambique, can provide
the higher level technology like a Caesarean section. Even with
these basic things it may make all the difference.
Q33 Sir Robert Smith: You think that
basic intervention locally is probably more practicable than trying
to get transport so people go to a more skilled centre?
Dr Kodindo: Yes. The health centre
will provide basic obstetric care. If the woman arrives and she
is already fitting and has eclampsia, the nurse there can start
to give her magnesium sulphate. If she is bleeding she may start
to receive some IV fluids and then put her in a position for her
to travel. When they arrive in the referral system they will be
in better condition and have even more chance to be saved. Sometimes
they arrive in this condition which is already very, very bad,
and it is very difficult to save their lives. We need to have
a two-level health system and a means of transportation. Three
months ago when I was in Ethiopia, women were living on the mountains
and deep down in the valley there were no commercial cars, so
sometimes they would just sit on the road waiting for an eventual
car to go by, and that may take days. In an emergency there is
no way—she or the baby would not survive. In the Congo it
is the same problem. It is a huge country; the roads are very
bad; there is no means of transportation; so accessibility is
the real problem, plus the weakness of the health system. In the
east of Congo when I was there two weeks ago there was one hospital
covering the whole area. In this hospital they had only two delivery
kits and sometimes three or four women went into labour at the
same time. They did not even have time to sterilise the delivery
kit before delivering another woman. This is an area where they
have a high incidence of HIV pregnancies. When we strengthen the
health system to prevent maternal deaths we are also strengthening
to prevent the spread of HIV. If in this hospital they have the
steriliser, they have more delivery kits, it will play on those
things. It will help to save a woman's life and help prevent the
spread of HIV. Women in this condition are coming to deliver and
they will go back with HIV contamination.
Q34 Ann McKechin: Dr Kodindo, I think
we can imply from what you have said this morning that the Government
of Chad really places no priority at all on the status of women
and the empowering of them. The question for donors such as DFID
is, what steps can they take to improve sexual and reproductive
health in countries such as Chad, where they face a government
which places very little or no priority on it and where there
is a very different cultural ethos around the issue of women?
In what way do you think that donors can try to fund other civil
society groups which are pressurising for the improvement of women?
Are there women's organisations which exist generally where we
can try and put these messages across? Which do you think is the
best way donors can help?
Dr Kodindo: There are many things
that they can do. The first step in empowering a woman is by improving
their health. If we improve their health we will give value to
their life. When we give value to the life of a woman, by preventing
them from dying or having bad health, we give value to her life,
and this is the first step in empowering a woman. DFID can also
have some pressure on the government of the countries because
until now it is sad to say but there is not much value to the
life of a woman. You would not believe it but in many of our countries
there is even no accounting of a woman's death. When I was in
the Congo two weeks ago they had one labour room and we saw a
register with 26 rows; even a row for placenta weight; but there
was not one row for maternal deaths. They are not even counting
maternal deaths. So, firstly, to have them start counting maternal
deaths. Make audits on the maternal deaths and take action on
that. Maternal deaths should not be something which is just a
fact of life. It should be counted and audited.
Q35 Ann McKechin: You think that
that should be a condition of any aid that is given by donors?
Dr Kodindo: Yes.
Q36 Ann McKechin: That there should
be proper statistical data?
Dr Kodindo: Yes. Then there should
be a cutting of the level of the maternal mortality in these countries.
They should do something about that. Women should not be left
just like that. What you have said about the women's organisations
I like that because maternal mortality to me is a human life issue.
The woman has the right to life. If we are left with a woman dying
we are violating the human right to life. The woman has the right
to good health. If you are letting them have a fistula, we are
violating their right to good health. This is a question I want
to ask you: why in the West when there is a risk of violation
of human rights, especially political human life does it make
headlines and people talk about it and are shocked, why not if
it is about a woman's death? This is also a violation of human
life. It should also make people react and judge and put some
pressure on the government to start to do something.
Q37 Ann McKechin: It is about issues
of governance or human rights in developing countries, and if
we give funding then the issue of maternal rights and issue of
women's rights are at the forefront?
Dr Kodindo: Yes, exactly. This
shows them that the woman's life counts. It should not just be
discounted.
Q38 John Battle: I want to ask you
a particular question really about blood banks and blood donation,
perhaps inspired by the film, because part of the drama of the
Panorama film was watching the blood go down in the packet
and there is no new blood coming in. I was reflecting on the film.
There was a brilliant book by a sociologist in Britain called
The Gift Economy in which he tried to spell out that one
way of ensuring that society held together was that people did
not sell their blood but gave blood to ensure that they or their
families when they needed it would find there was a supply there.
Quite a few people in Britain carry cards and give blood. If the
blood banks go down there are appeals on television and people
go from work, queue and give blood. I do give blood but the only
time I cannot give blood is if I have visited a country with malaria.
I want to know, is there a specific reason why that gift economy
cannot work in African countries? Is it a scientific problem because
of malaria? How could that problem and the lack of blood availability
and blood banks be addressed?
Dr Kodindo: I do not think it
is because of malaria. There is a very bad idea of giving the
blood. In some places they think that if a man gives blood he
will become impotent. There is some cultural belief. They think
that if you give blood you will lose weight. Some cultures do
not believe in talking about that. I remember the time when they
used to provide some sandwiches to people and give them some food
and people used to come to give blood. Maybe people should be
more sensitised about that. Right now it comes down to the relative
to give blood. If there is no relative then there is no way to
give blood.
Q39 John Battle: Do governments not
campaign or press it on blood banks?
Dr Kodindo: No, the government
is not really campaigning.
11 Reproductive Health Access, Information and Services
in Emergency Settings (RAISE) Back
12
Emergency Obstetric Care (EmOC) Back
13
Intravenous (IV) Back
14
Dr Songane volunteered this information from the Public Gallery. Back
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