Vol. 72/No. 37      September 22, 2008

Oyono was pointing out that the public health system in Equatorial Guinea is being built through the growing numbers of Guinean doctors, graduates of the new medical school here, who today are working with volunteer Cuban medical personnel in cities and towns across the country.

During a two-week fact-finding trip to Equatorial Guinea in July and August, internationalist supporters of New York-based Pathfinder Press had the opportunity to visit hospitals and clinics and talk with doctors, nurses, and medical technicians working in nine different regions of the country, in the process learning about the expansion of public health programs here. An article on broader developments in the country, “Equatorial Guinea: Changing economic and social relations highlight realities facing millions in Africa,” appeared in the September 8 Militant.  
 
Imperialism’s toll in Africa
Equatorial Guinea shares with the rest of Africa a centuries-long legacy of colonial and imperialist domination. The health conditions facing the peoples of the continent today are a graphic expression of this exploitation.

Every year millions in sub-Saharan Africa are killed by preventable or curable diseases. More than 3 million people die yearly from HIV/AIDS, tuberculosis, or malaria, according to the World Health Organization (WHO). The AIDS pandemic has particularly ravaged southern Africa—in Zimbabwe an estimated 20 percent of women between the ages of 15 and 49 are infected with HIV, and about the same percentage in South Africa.

Diarrheal diseases—preventable with clean water and simple hygienic measures—are another leading cause of death, especially among infants. More than 40 percent of the population of sub-Saharan Africa lack access to safe water, according to WHO estimates, and the reality is undoubtedly worse. Widespread malnutrition contributes to the ravages of disease at all ages.

Of the 20 countries with the highest maternal mortality rates in the world, 19 are in Africa. Some 43 percent of the world’s children who die before reaching the age of five are African. Infant mortality rates are as high as 165 per 1,000 live births in Sierra Leone and 154 in Angola, compared to the national average of 6.9 in the United States. Life expectancy, which stands at 79 in the United Kingdom, is reported to be 45 in Nigeria and 38 in Angola.

Equatorial Guinea, while far from the worst-off on the continent, faces this same legacy. Until a decade and a half ago, paved roads and telephone service barely existed, let alone access to health care. Few outside the two largest cities had access to electricity. Even today it is a country with virtually no industry, and land cultivation is largely subsistence agriculture.

During the first years following independence from Spain in 1968, several hospitals were built in the largest provincial towns by the government of Francisco Macías Nguema. But what became an 11-year reign of terror under Macías led to the deterioration of hospitals and clinics and the exodus of trained medical personnel. No institutions of higher learning had ever existed in the country, and few Guineans who managed to study abroad, whether in medicine or any other field, returned to the country. (See accompanying article on the country’s history.)  
 
Malaria endemic in region
As in much of Central Africa today, malaria is endemic in Equatorial Guinea. Typhoid fever, tuberculosis, and intestinal parasites are also widespread. HIV/AIDS, though less severe than in many other countries of sub-Saharan Africa, is increasing. Only 28 percent of the population has access to sanitation services, and even in urban areas water available through municipal distribution systems is not safely drinkable. It must first be boiled or chemically treated. According to La Gaceta de Guinea Ecuatorial, a magazine widely circulated in this country, average life expectancy at birth is 54 years.

Since the discovery in the mid-1990s of substantial oil deposits beneath the territorial waters of Equatorial Guinea, the government has used considerable resources, largely derived from petroleum production, to develop the country’s infrastructure. Upgrading the health-care system has been one of the goals.

A broad program of medical cooperation between the governments of Equatorial Guinea and Cuba was established in 2000. Cuba agreed, among other things, to send medical brigades to help staff hospitals and public health centers throughout Equatorial Guinea. Today 160 Cuban doctors, nurses, and lab technicians are working in 18 of the country’s 21 districts, including the most remote areas. The brigades, which are as large as seven or as small as two—a doctor and a nurse—live in the communities they work in, sharing the conditions of life of the population.

The cooperation agreement also included creation of a medical school here in Bata, the largest city, as a professional school of the national university. Its purpose is to train hundreds of Guinean doctors and nurses to progressively replace the Cuban medical personnel who provide almost all primary medical care.  
 
Guinean doctors today lead hospitals
Since August 2006, when the first class of 73 students graduated from the medical school, dozens of Guinean doctors have begun working at health-care centers across the country side by side with the Cuban physicians, nurses, and technicians. Their combined efforts are already having a palpable impact.

The medical director of every public hospital we visited was a recently graduated Guinean doctor, and we were told this is true in other districts as well. Their confidence was striking, and their solid medical training is beginning to transform relations within communities in ways they described with optimism.

In Evinayong, a provincial capital of 34,000 inhabitants in the south-central region, the medical director of the hospital is Dr. Santiago Nguema Ndong, a native of that city. We had met him on a previous visit in October 2005, as he and 19 classmates were about to leave for Cuba for their final year of medical school.

“Malaria is the number one health problem we face,” Nguema told us. “It is the main cause of infant mortality.” In areas where the medical brigades have been working for the last eight years, Nguema and others reported, the number of infant deaths has begun to be reduced, due to the timely treatment of more patients and through preventive efforts.

Statistics on such questions, however, are often unreliable throughout much of sub-Saharan Africa. This is another of the challenges now being taken on by district hospital staffs as they gather records and begin to compile more accurate statistics.

World Health Organization figures for 2006—the most recent available—list the infant mortality rate for Equatorial Guinea as 123 per 1,000 live births. But records compiled by the medical brigades show that in 2002 the overall average for infants treated by the hospitals and clinics the brigades service was 47 per 1,000 live births. By 2007 that figure was reduced to 16.5 per 1,000. In the areas served by the Evinayong medical brigade, infant mortality was 35 per 1,000 for the first half of this year.

María Elena Núñez, a nurse working in Evinayong, reported there had been only one maternal death at that hospital in the past year and a half. This is a significant achievement in a country where, according to WHO figures, the number of maternal deaths is 880 per 100,000 live births.  
 
Impact of lack of electricity
The prevalence of many diseases long ago eradicated in the advanced capitalist countries is primarily due to the absence of any infrastructure providing safe drinking water, sewage disposal, or the eradication of disease-carrying insects. The lack of electrical power, reliable means of communication, and passable roads compounds the difficulties.

Outside the two major cities of Malabo and Bata, electricity is available a few hours a day. In the largest provincial capitals—Ebebiyin, Mongomo, and Evinayong—generators, when running, provide electricity for 12 hours a day, from 6:00 p.m. to 6:00 a.m. Elsewhere it is usually available, at best, five hours a day, from about 6:00 p.m. to 11:00 p.m. As the medical personnel in Ebebiyin pointed out to us, that means doctors cannot perform even emergency surgery during the day, unless the hospital has a functioning diesel generator, which many don’t.

“When you have to draw blood from a patient at night to run a lab test, it’s hard to even find the vein when you have only a flashlight or a kerosene lamp,” we were told by Dr. Amarilis Contreras in the north-central town of Añisok.

At the hospital in Niefang, doctors showed us a brand-new premature infant incubator that had been donated some time ago by ExxonMobil, one of the major U.S. companies exploiting deepwater petroleum deposits in Equatorial Guinea. The machine was sitting in the hallway, still tightly wrapped in protective plastic. Without reliable, round-the-clock electricity, it was unusable, the head of the pediatric unit explained. And ExxonMobil donated neither a generator, nor the fuel to keep one running.

As noted in the first of these articles, there is no national electric grid in Equatorial Guinea; each city and town relies on its own generators. A hydroelectric project, currently being built near Añisok, is expected to provide electricity for continental Equatorial Guinea when it is completed within five years.

In Kogo, in the extreme southwest corner of the country, the terrain and transportation difficulties make it hard for patients from the surrounding area to get to the hospital. Kogo is an isolated town on the edge of a river delta with extensive mangrove swamps. Mosquito-borne malaria and sleeping sickness, which is transmitted by tsetse flies, are even more prevalent than in other parts of the country. Cuban doctors, who have been trained to work and provide care under even the most onerous conditions, travel by canoe to hard-to-reach villages (as hundreds volunteered to do in Mississippi and Louisiana following Hurricane Katrina—an offer impudently rejected by Washington).

“We often made trips that took four hours by boat, then a long walk,” Dr. William Pérez, a Cuban volunteer who worked in Kogo, told us. “I had the bitter experience of seeing a child who died on the way to the hospital because the trip took six hours.”

Now, for the first time, the narrow coastal path between Mbini and Kogo is being turned into a paved road that will be passable year round.

In several towns we were told by medical personnel that many patients who test HIV-positive cannot afford to go to Bata, the only city on the continent where a reliable diagnosis can be made and appropriate treatment initiated.  
 
Expanding medical knowledge
Doctors in every town we visited explained that one of the challenges they face is convincing local residents to go to the hospital for medical treatment. Many, they said, have grown up accepting disease and death at an early age as a fact of life. Superstition and confidence in traditional tribal healers, known as curanderos, lead many patients to come for medical help only when it is already too late. That is a major reason many children die of malaria, which is usually not fatal if treated in time.

“Last July a 27-year-old teacher here died from AIDS,” Dr. Contreras told us in Añisok. “She had gone to a curandero instead of the hospital. We often hear people call AIDS ‘the bad luck disease.’”

Systematic popular awareness efforts have helped convince greater numbers of people to go to the hospitals and clinics for treatment. Dr. Juan Alvarez Morell, head of the medical brigade in Evinayong, said brigade members speak on “weekly radio programs and give talks at the hospital and in the community to educate about infant malaria, diarrhea, and other health problems. We promote our vaccination campaigns.”

A notable change is happening as young Guinean doctors take charge of hospitals and integrate themselves in medical programs around the country. They are reaching out to traditional curanderos and parteras (midwives) to win their confidence and train them to recognize medical conditions that need immediate hospital care. The young doctors are convincing traditional healers to help get people to go to the hospital and clinics. Results vary from area to area. But Dr. Marcelino Edjang Ondó, the hospital director in Niefang, reported they have had success there in working with the curanderos.

“Traditions don’t change overnight,” said Dr. Dayamí Escalona, head of the medical brigade in Niefang. “We find ways to link our use of modern science and the work of the curanderos to win their cooperation.”

That the Guinean doctors, whose mother tongue is the indigenous language, most often grew up in the area and are known in the community is a great aid in gaining the confidence of patients and the cooperation of traditional tribal leaders in working with the curanderos and parteras.  
 
Rebuilding hospitals
In about half the hospitals we visited, major rebuilding and repair work was under way. In three towns—Mongomo, Evinayong, and Luba—the old structures had been gutted, and largely new buildings were going up inside the shell. The dilapidated condition of almost all public hospitals in the past is slowly being transformed—a measure of the resources the government of Equatorial Guinea is putting into upgrading the primary health-care system.

The gap between facilities available to working people and to those with substantial wealth, Guineans and foreigners alike, was brought home to us, however, by a visit to the Centro Médico La Paz. This ultramodern private hospital here in Bata, an Israeli-run project organized in collaboration with the government of Equatorial Guinea, opened at the end of 2007. A similar hospital is under construction in Malabo.

Most of the 35 doctors on the hospital staff—in their majority Israeli, with some from Argentina, Uruguay, and other countries—are not resident in Equatorial Guinea. They fly into Bata for a few days or weeks at a time. Three of the doctors are Guineans, recent graduates of the medical school here.

We toured the Centro Médico La Paz following the signing of a research agreement between the hospital and the national university. Noting that they had performed neurosurgery there just the day before, director Alon Stamler told us that the hospital is equipped to do the most advanced procedures, making it possible for patients seeking the best-quality care to stay in the country instead of going abroad. Stamler remarked that the international oil companies, whose personnel work sometimes dangerous jobs on offshore platforms, would be among the most appreciative of the medical services the center offers, adding that the new hospital in Malabo hopes to establish long-term corporate contracts with these firms.

The hospital is pay-as-you-go. One night’s stay costs $325, an X-ray $200, a doctor’s visit $225, a CAT scan $350. (Many Guineans live on less than a dollar or two a day.) Few beds were occupied in the wards we were shown.

In a conversation after the guided tour, two professors from the national university who had taken part in the visit told us they were proud this facility now made such advanced care available in their country. When asked who would be able to afford it, they ruefully replied, “Hardly anyone.”  
 
Need to train specialists
In the district public hospitals, the number of operations being performed has doubled over the past eight years. But Dr. Juan Carlos Méndez, head of the Cuban medical brigade in Equatorial Guinea, noted that most of these are minor procedures. For serious operations, patients still must go to Bata, where the hospital has surgeons and more advanced equipment.

“We need to train more surgeons and other specialists for our hospitals,” said Dr. Edjang of the hospital in Niefang, where three doctors, two Cuban and one Guinean, are working.

Building on the initial progress, this challenge is being addressed at the medical school in Bata, where several students have now finished their first year of training in surgery, internal medicine, or obstetrics/gynecology.

The third and final article will report more extensively on the medical school, and on the launching of an extension program by the National University of Equatorial Guinea allowing students who do not live in Bata to carry out the full medical school program in their home towns.

Brian Taylor and Omari Musa contributed to this article.
 
 
Related articles:
Background on Central African nation  
 
 
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