Examination of Witnesses (Questions 40
- 59)
TUESDAY 16 OCTOBER 2007
DR GRACE
KODINDO
Q40 John Battle: They do not see
it as their job as ensuring there is a blood bank to back-up a
clinic or hospital?
Dr Kodindo: Exactly. This is why
I am saying there should be a stronger commitment from the government
on this problem of maternal mortality. If there is a real commitment
and a real political will to address the problem of maternal mortality
they will do all this, factor that, go along with the prevention
of maternal mortality and lack of blood transfusion. If there
are blood transfusions in hospital it will not only benefit the
women but the men and everybody.
Q41 John Battle: Let me ask you,
is there a better blood bank in cities than in rural areas? Do
the rich get access to blood? Do they store their own blood to
make sure they have got a supply, because not everyone can guarantee
perfect health and never needing some blood?
Dr Kodindo: In rural areas in
most African countries they do not have blood banks. They do not
have it. This is why many women are still dying from haemorrhage.
The rich people, as you have said, they have a way and they also
rely on the relative.
Q42 John Battle: They rely on their
relatives as well?
Dr Kodindo: Yes. In some countries
the International Red Cross is also providing some blood. In Ethiopia
the Red Cross is one provider for blood.
Q43 Sir Robert Smith: On this blood
issue, obviously there are all the cultural and other logistical
issues. Is there also the practical expense and reality that you
need to have storage, refrigeration and all that management?
Dr Kodindo: Absolutely.
Q44 Sir Robert Smith: In a sense
fresh blood donated at the time it is needed is an easier thing
to manage than long-term storage?
Dr Kodindo: Yes. Of course this
is logistically is very important.
Q45 John Battle: That is why you
would have queues of people at the time of a crisis outside a
hospital giving blood, but if there is no pressure to do that—
Dr Kodindo: There is no pressure.
Q46 John Battle: Is the World Health
Organisation pressing? Which of the UN agencies understands the
need for there to be blood supplies and actually actively campaigns
for it?
Dr Kodindo: This is why I think
the role of the UN is very important in telling the government
to make all that effort and campaign and to try to reduce maternal
mortality and address the causes of maternal mortality.
Q47 John Battle: What I am specifically
asking, just as for tackling some diseases—for example,
I am thinking of the campaign for polio, the World Health Authority
pushed very, very hard to get a very simple measure through as
a means, and there were some cultural resistances—does the
World Health Authority press for there to be blood available and
for countries to take that seriously?
Dr Kodindo: Yes. That will really
help to put pressure on them.
Q48 James Duddridge: Of emergency
obstetric cases, what proportion are a result of abortions, attempted
abortions or unsafe abortions, in Chad and generally?
Dr Kodindo: The proportion of
deaths from unsafe abortion is very, very high in Chad. Generally
it is about 13 % globally. In Chad I would put it as maybe the
second cause of maternal deaths, especially among adolescent teenagers.
These are the ones with the least access to the contraceptive
method.
Q49 James Duddridge: What are the
medical complications, and how can they be treated? What do you
need to be able to treat people presenting?
Dr Kodindo: Haemorrhage and infection,
so we need antibiotics. For those who have seen that film of mine
the 12-year old girl needed to have antibiotics and a blood transfusion
but since we did not have them in the hospital her mother had
to buy it. The small capital that she has she spent it in the
first 24 hours buying, first, a small syringe and IV fluids. When
it came to stronger antibiotics, which are much stronger against
anaerobic infection, she just could not buy them. Only antibiotics
will treat the post-abortion infection.
Q50 James Duddridge: Can you tell
us more about the abortion laws in Chad and any proposals to change
those laws?
Dr Kodindo: Chad, like many African
Francophone countries, has inherited the law of France, some 1920
law, so abortion is illegal in Chad. Until now there is no talk
about that. I am only a doctor. I do not know much about that.
I can only talk about services that can help me save a woman who
has had an unsafe abortion. This is what I need to save their
lives. Being only a health provider I have really no power on
that. There is no talk about changing it. It is the old law of
France from 1920.
Q51 James Duddridge: Is there anything
more that can be done to reduce maternal mortality in countries
where the law restricts abortion?
Dr Kodindo: Again, as I told you,
I work in countries but I cannot talk about changing the legal
system. This is not really what I am supposed to do. I am just
a health provider. For me when any woman who comes because of
an unsafe abortion, or a spontaneous abortion, what I should do
is treat them and try to save their life. I cannot change the
legal systems of the countries.
Q52 James Duddridge: How formalised
is the system of unsafe abortion? Who actually carries out the
abortion? How formal is the system in various countries? Is it
done at the local village level by family members, or is it a
paid service although illegal?
Dr Kodindo: This is the big problem.
Usually since it is illegal they do not go to the national health
system; they use some people in their city. It is done in very
bad conditions. When they are brought in it is the worst complication
and we have to deal with that and sometimes you cannot save them.
For some of the women we have to do major surgery on them in order
to save them, like a hysterectomy.
Q53 James Duddridge: Are there some
countries where it is illegal for proper medical professionals
to intervene where there has already been an attempt at an unsafe
illegal abortion?
Dr Kodindo: No, we do not have
this problem, not in Chad. As a health professional you just have
to provide the appropriate treatment to the patients. You have
no right to refuse to treat her because she has had some induced
abortion.
Q54 Hugh Bayley: First of all, what
do you think is needed to change what donor countries and the
governments of developing countries and international agencies
are doing to catalyse change to give us a chance of meeting the
MDG goal by 2015?
Dr Kodindo: It is a really important
question because MDG is lagging. There is always something to
start now. This is an urgent situation. The donors should work
with the government and they should start up a real commitment—a
commitment that should be translated into concrete actions, like
putting some pressure on the governments to start to adjust and
implement. We know what to do to prevent women from dying, and
these are technologies that are not even sophisticated. It is
possible to reduce maternal mortality. It has been shown here
in the West; it has been shown in many countries that my previous
colleagues have talked about—North Africa, Egypt and many
of these countries. They should start having long commitments,
a real commitment that should be translated into investing in
infrastructure; also providing for supplies, and very simple basic
supplies; antibiotics; magnesium sulphate; very simple supplies
and drugs; work on the roads; work of the Ministry of Transportation;
educating; and developing human resources, and the mid level human
resources because you may not have enough specialists. You need
the skills and medical care to cover the area where access is
very difficult now like the rural area. Focus on these places,
the rural area and the displaced person with the situation of
insecurity and extreme poverty. Increase the coverage of these
areas and it will make some change. In a few years you will see
the change for yourself, but it is very difficult to achieve and
we need a long-term commitment. It may not take days or months
to register a reduction in maternal mortality; it may take more
than that. This is why we need a really long-term commitment and
accountability.
Q55 Hugh Bayley: It seems to me as
a politician that if you want to drive an administrative and political
change you need a very, very clear idea of what it is that you
are trying to do. In this session I have become aware that this
is a very complicated problem, with many difficult inter-related
things—education, family relationships, medical interventions
and so on—but also many, many agencies involved in the field.
It seems to me that there is great confusion about what the priorities
are. Your answer to an earlier question, helped by Dr Songane
behind you, put a very simple idea into my head. You tell us that
it would cost 4.5 billion to provide safe childbirth for 95 %
of the world's population. Dr Songane tells us that there are
just under 150 million children born a year—that is $30
per child. $30 per child born in the world would provide safe
childbirth for 95 % of children. Should we start at least with
a campaign that says to each developed country government, "Unless
you stump up $30 per child; put it into a fund controlled by women
locally, which is transparent and open, you are not going to meet
this target"? Is that too simple? $30 per child, should that
be the campaign? What I have calculated, you say that some economist
has worked out that $4.5 billion would provide safe childbirth
for 95 % of children. Dr Songane tells us that there are 150 million
children born a year, slightly fewer, but roughly. If you divide
the amount it costs for safe childbirth by the number of births,
it would cost about $30 per birth. Should we not just have a global
target that the government of every developing country puts $30
per childbirth—they can estimate in Chad how many children
are born a year?
Dr Kodindo: We have about 10,000
deliveries per year.
Hugh Bayley: For a community with 10,000
deliveries the government would need to provide a fund of $300,000.
Chairman: In the UK we provide a maternity
allowance so would that help if you actually gave women money,
for example?
Q56 Hugh Bayley: You have taken the
idea even further than I have, but that is probably one way. So
long as you find a way of averaging out between the cost of a
Caesarean. What I am saying is: should we encourage all the agencies
here to launch a campaign that will pledge, whether it comes from
donors or country governments, $30 per birth?
Dr Kodindo: I think we should
try. We should start to do something.
Q57 Chairman: I think the point behind
Mr Bayley's question, and I think Ann McKechin was making the
point, is that, sadly, in some countries you give the money to
the government and it does not seem to get through to the women
who need it. If you actually gave it to the women themselves who
were pregnant in some form or another in a way that was guaranteed
access you may cut through some of these problems—whether
it is lack of will, corruption, or whether it is because at least
you empower the women in a practical sense. The kind of people
that we saw in your film having to go and buy blood, drugs and
so forth, for a start with transport they would at least have
some basic means of doing it, and not have to go to their husband
or somebody else and get permission because they could actually
do it themselves. Would that make a contribution to solving some
of the problems?
Dr Kodindo: Yes, but I still think
the health system should be strengthened. Without a stronger system
nothing much can be achieved. We still need to invest in the health
systems.
Q58 Hugh Bayley: I take your point
about diverting money.
Dr Kodindo: The corruption is
a reality, especially in a country where the maternal mortality
is high. If you have to restrict the money because of that then
we are not really helping the problem of maternal mortality.
Q59 Hugh Bayley: If you actually
handed out bank notes the money would not be spent on maternal
and child health, it would be spent by the men for good or bad
other things. I understand it has to be kept within the health
system, but somehow we need to focus people's attention on the
fact that, compared with universal medication for HIV, this is
a cheap and doable problem?
Dr Kodindo: Yes. This is why something
should be done. Of course it is something that can be achieved;
it is possible. You have shown it here. It is possible. It is
not even asking for super-technology, as I say; but it is possible
if only the donors and the government have the same commitment.
If they have the same will and they have an integrated strategy,
coordinated strategy within the donors and within the government,
we will see the result. This is why something should be done,
and now.
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