Does the Cameroon Health Sector deserve Patients' trust?   

     One fundamental condition for a good doctor-patient relationship is the patient's trust for the doctor; trust with his health and life. This trust  entails that any intervention is for the benefit of the patient  and is not only for the doctor, but the entire institution he works in, the entire medical system and other services the patient might be sent to. This therefore means that the doctor, the institution and the medical system have to function effectively to maintain this trust, for loss of this means loss of the nobility in the practice of Medicine.

   The doctor therefore has to keep his medical knowledge up to date, maintain a good performance, be polite, be truthful, be considerate, respect patient's privacy and dignity and be readily accessible among other responsibilities.

   The institutions have to ensure that the doctors get the above, coordinate the activities of their various departments, maintain medical ethics and enforce a high standard of practice amongst others.

    The system (here I will add the Cameroon Medical council and the ministry of Health together) has the responsibility, among others, to protect, promote and maintain the health and safety of the public. They have the responsibility to ensure the fitness of any doctor to practice, the compliance of all institutions to let-down rules, regulations and guidelines, etc.

    Working in a mission hospital in Cameroon for three and a half years and seeing many patients having this trust, I always wondered if it wasn't really a blind undeserving trust. How have our medical practice in Cameroon earned us being trusted by any patient?

   The medical council seems unable to protect the patient and is unable to enforce any fitness to practice regulation for doctors, especially in the non-government hospitals. Anybody calling himself a doctor, and having a paper to show for it can practice in Cameroon. In most cases, some foreign-trained doctors practice even without being recognised by the Cameroon Medical council or the ministry of Health. How then can someone just move into another country, negotiate with an institution and start working? In some cases, they cannot even communicate in English or pidgin, but are working in the North-west for example, where majority understand these languages.   Up till 2002, the Council did not even have a credible office where one can make inquiries or lodge complains; it existed only in paper, with documentations being done in private clinics in Yaounde and in Douala. It was only in 2002 that they acquired a building and are asking all doctors to pay 50,000 frs CFA for it (this is about a third of the monthly salary of a newly qualified doctor). But Cameroon had independence more than 40 years ago, what have we been doing?

One might want to wonder what the selection criteria are for foreign medical graduates.  All the council require, no matter where the doctor trained, if he trained at all, is certified copy of the certificate, some other certified copies and 25,000frs. A Cameroon trained doctor cannot be licensed in neighbouring Nigeria without passing the Nigerian Medical and Dental Council boards exams (not to talk of UK, US etc), but a Nigerian trained one, or one trained anywhere in the world can be licensed in Cameroon without any assessment. Now then how can we guarantee the adequacy of any training or are we in effect saying that we are so low that none can be lower?

  Our institutions are no better. Here, Sadly enough, hospital administration has been left in the hands of people with little knowledge of the practice of medicine and hospital administration and in some cases, little conscience. I still cannot forget the battles we had in policy change when we realised in 1999 that some mission hospitals were not screening for Hepatitis B in blood to be transfused. To show how powerful the administrators are, it took 8 months for this to be changed! How long this has been practiced is left to your imagination. Guidelines on major procedures like blood transfusion are littered everywhere and the facilities to carry them out are available; why they should not be carried out properly is an offence worth investigating!  However, we live in a country and in an era where anything goes. Patients were just left to their fate.

It is so sad to see that in our hospitals, just like in most institutions in Cameroon, the quest for power and control has intoxicated the administrators, and these are used largely for selfish purposes. In most cases, the doctors are made to know who "The Boss"is!

   One cannot have a discussion like this without talking about doctors themselves who continue to constitute a large part of the problem. They are the ones running the medical council and the ones who have been schooled and supposed to be intelligent. They suffer under the yoke of the following;

-          Low wages.

-          Pressure from society to live up to a certain standard.

-          Working under administrators who have somehow re-defined the practice of medicine (especially Mission Hospitals).

-          Not having any institution that regulates their practice.

-          Working in under-equipped facilities.

-          Working extreme long hours.

  The practice of medicine has boiled down to doctors showing  their 'doctor-hood' to themselves, colleagues and patients, and forget the real definition of Ëœthe practice of medicine', which entails continuous learning at times even from patients.  

 How sad when what should actually be meaningful interactions among themselves usually end up being a cesspool of self aggrandisement; just like a mechanic telling you the other mechanic is not fixing your car well.  Doctors have been known to treat their colleagues very unfairly and make malicious and unfounded criticisms of them; at times even in the presence of patients! At the end of the day, the patient then does not benefit from meaningful interaction amongst those taking care of his health and life.

Institutions and doctors themselves put little emphasis on continuous medical education and in the face of worsening health conditions this is not acceptable.

  All in all, it is high time the Cameron Health sector evaluate itself in the light of providing its very essential service to the population. Due to the failures of this sector, many patients have had to take decisions that have not been beneficial to them and if this continues, the consequences will be severe for this and future generations.

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	Non-Conventional Healthcare Practice in Cameroon: How Safe?
			"A healthy man is, above all, a man of this earth, and he must, therefore, only live the life of this earth for the sake of order and completeness. But as soon as he falls ill, as soon as the normal earthly order of his organism is disturbed, the possibility of another world begins to become more apparent, and the more ill he is, the more closely does he come into touch with the other world." ---- Dostoyersky crime and Punishment 1. Introduction Taking a trip in one of Cameroon's inter-city buses, or a walking on a street in any of Cameroon's cities; perhaps listening to any of the numerous FM Radio Stations, a visitor to Cameroon will be appalled by the numerous adverts of non-orthodox health remedies or the so-called non-conventional or alternative health remedies. This sector having broken the tradition of waiting for patients and is now getting close to them. That the resolution of the Alma Ata conference of 1978 for healthcare package to be taken to the people's doorsteps is going on should be a jubilant issue for Cameroon and its people; after all, the declaration specifically states that "mobilisation of traditional medicine systems is the only way to make health for all a reality." This conference viewed primary healthcare as essential healthcare based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. However, the content of healthcare package in terms of how practicable, scientifically sound and socially acceptable it is, is one that is and will always be of much concern to the conscious Cameroonian, because a wrong package delivered even the right way leads to nothing else but disaster. 2. Overview of Various Healthcare Providers. It is amazing at the different types of individuals dabbling in the sea of curative healthcare provision in Cameroon; all with different principles underlying their art, and not belonging to western medical family as their only common foundation. These have have capitalised on the population's lack of trust for the national healthcare system. They now grow at the alarming rate and at present see more patients than modern medical practitioners. In an attempt to distinguish them, the following categorization has been adopted. 2A. The modern herbalists These are the people who sell remedies supposedly made from herbs. They claim to have studied textbooks of natural preparations. One can find them in every nook and corner of Cameroon's cities advertising their products. An experience with these charlatans in a city bus per se, is an item of commedy epitomizing a complete abuse of medical information. Most of these folks are secondary school dropouts and have humour as their only qualification. They parade strange looking concoctions in old penicillin bottles. They market it as a wonder drug with an exaggerated posibility to treat as many as twenty different diseases; epilepsy, sickle cell disease, impotence etc. These concoctions are home made from a mixture of different herbs and packaged under unhygienic conditions in makeshift local laboratories. On the streets, one can find these herbalists with herbs and grass of all sorts, confidently explaining the medical indication of each grass such that an unwary student of pharmacognosy will be stunned and awed. The fact that these Herablists can just mix anything under any condition and sell to the public under the watchful eyes of health officials and forces of law and order highlights the laxity for implementing the rule of law to safeguard public health in Cameroon. 2B. Traditional herbalists or practitioners of African traditional medicine. These ones are no new comers to the field, as they have always existed in African healthcare delivery terrain even before the arrival of western medicine. Traditional medicine, as defined by WHO, includes diverse health practices, approaches and beliefs incorporating plant, animal, and/or mineral based medicine, spiritual therapies, manual techniques and exercises applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illness. In a country like Cameroon where traditional medicine has not been truely incorporated into the national healthcare system, it is classified as an alternative medical practice. And attempt has been made to differentiate a herbalist from a witch doctor and seer, as a pure herbalist does not rely on communication with spirits of the ancestors or some other unseen powers to treat their patients. However, the distinction between the various sub-categories can be blurred as most of them borrow from each other. What is interesting is the attempt at revolutionising their products; now having pre-package combination of herbs sold in the open market. There are others with commodities like elephant skin, crocodile tooth etc. which are supposed to be of great medicinal value; not forgetting the local viagra, a root said to have aphrodisiac properties and very popular with ageing males. They have actually helped many people in Cameroon. Their health value has been recognised by Dr. Luc Montagnier, who discovered HIV. Dr Montagnier recently stated that "certain traditional treatments may indeed have real therapeutic properties". He enjoined Cameroonian traditional herbalists to run empirical tests on their products. Some of these Traditional Herbalists largely rely on human engagement and spirituality as tools for promoting well-being. The growing interest in them only attests to a substantial interest in regaining humanistic perspective which is in contrast to western medicine that rests largely on the axiom of Cartesian dualism - the separation of body and mind, based on the premise of healing is to correct disease by using medical and surgical procedures. However, it is also good to recognise that some of these herbalists have maimed and killed lots more considering the vast number who have either died or had serious disease complications due to total neglect in the hands of these quacks. The lack of proof of authenticity of their products, the unhygienic nature, lack of safety profiles, unproven efficacy and lack of a precise and harmonised dose is a source of worry. In addition, their practice is shrouded in secrecy and superstition. One herbalist does not know the content of another herbalist's medicine, making it difficult for knowledge to be shared. 2C. Practitioners of Chinese traditional medicine (CTM) This is another group that is quickly and comfortably carving a niche market in Cameroon. They are fast becoming the wonder-boys of curative medicine. They are expanding their tentacles throughout Cameroon's ten provinces, consulting patients (mostly through interpreters), and dispensing purported Chinese medications. Some of these Healers rely on acupuncture, therapeutic aromatherapy and therapeutic massage therapy. It is important to observe that CTM has undergone a major revolution since 1946 when it was officially recognised in China as being on par with western medicine and the creation of regulatory bodies to oversee its practice. And since then it has been increasingly made scientific, with the creation and maintenance of courses on CTM in Chinese Universities. The vigorous teaching of students through in- service training, correspondence courses, evening schools, tutorial education, etc contributes to the advancement and propagation of CTM in China. Also, several joint ventures of Chinese drugs and some international scientific research centres have been established in China and elsewhere, with economical and technological cooperative relationship set up between China many developed and developing countries. However, translating the success story of CTA in China to the Cameroon terrain where the regulatory body on CTM practice is ineffective is a cause for concern. How can one be sure that the real Chinese medicine is being practised in Cameroon anyway? As a science, there should be cooperation with practitioners of orthodox medicine as a means of enhancing adequate health care provision. However, this is lacking, with very little communication between the two. One frequently observes patients bradishing their medical histories and prescriptions in the Chinese language. How then does medical continuity take place in a country where the official languages are English and French? 2D. Holy healers These are preachers of well established spiritual churches who claim to invoke divine healing on patients. They have an ever-increasing flock seeking socio-psychological opiate to ease their anguish. They have turned their churches into healing centres where patients are known to spend time, on no medication, simply waiting for these preachers to invoke God's healing power on them. We do not wish to deny or accept the existence of miracles, but for preachers to preach divine healing and 'no medications' to seriously ill patients with the end result being loss of human life is an act deserving reprimand. Their inclusion here is for sake of completeness as one finds it difficult understanding where they fit in the healing terrain other than by providing spiritual support and psychological placebo to patients. 3. The Role of The Media The media in any nation should aim to entertain, educate and inform the population. It should strive to expose bad practices and uphold the good side of society. However, the liberalisation of the media in Cameroon helps quacks and quackery healing practices to flourish. Listening to local FM Radio Stations in Cameroon, one hears noisy adverts from Alternative medicine practitioners publicizing their purported modern Traditional clinic with the wonderful efficacy of their products. Strangely, some of these quacks themselves, when ill even with the a light headache, are seen receiving treatment in various orthodox health facilities. Their infiltration of the health sector in Cameroon and the rampant exposure of their products with purported wonderful natural remedies, coupled with their health shops selling nutritional supplements of doubtful efficacy, these "Healers" are a threat to societal wellbeing. Cameroon presents a scenario in which anybody can advertise any herbal product on the radio with very little censorship. This, without doubt, is a danger to public health. 4. Social Acceptability In general, one is amazed at their clientele ;as fine educated men and women as well as the illiterate village peasants, all consuming the 'wonder drugs', bathing with the wonder soap, eating the wonder leaves or following the wonder regimen in the face of overt and life threatening diseases. WHO report shows that about 80 percent of Africans use alternative healthcare. How Africans have accepted this system only adds credit to Vera Burman, a western trained psychiatrist, who in her book 'Living in two Worlds' describes a typical African as being traditional, non-rational, intuitive, subject-oriented and human, as opposed to a westerner who is largely rational, intellectual, object-oriented and technological. The inability of western medical science to adequately address African cosmology of health, its high cost and low accessibility are responsible for the sustained social acceptance of this sector. 5. The Way Forward. Alternative medical practice has been implemented for a long time, the world over. It has many success stories that can be transfered to Cameroon. However, for a country that boasts of more than 8000 traditional herbalists as against about 1300 medical doctors, an indigenous way has to be sought to enhance the cooperation of the Orthodox and Alternative medicine providers. It should be noted that the Cameroon government, in law 81/12 of 27th November 1981 approved the fifth five year social, economic and political development plan (1981 - 1986) of Cameroon under which the traditional medicine service was created within the community medicine unit in the Yaounde central hospital and set up the office of traditional medicine in the ministry of health; in an attempt to integrate this practice into the national healthcare system. However, it is still not very effective, and very little improvement has taken place. Thus, it is imperative that those sections that are beneficial to the society be supported and promoted, while the rest should be barred from carrying out healthcare activities. Just like in the European Union, all phyto-pharmaceuticals should be subjected to general drug regulation and like synthetic drugs must comply with criteria of quality, safety and efficacy. Especially so as the decade 2001 - 2010 has been declared the decade for traditional medicine and medicinal plants by the African Union. In order to harness the richness endowed in our alterative healthcare systems the following strategies, advocated by WHO, have to be put in place. i) Implementation of a firm national policy, creating regulatory and legal mechanisms for promoting and maintaining good practice. This is very important in Cameroon where traditional medical practices are yet to be fully integrated in the healthcare system. Lack of this will only breed the numerous fakes and quacks that constitute a large part of this sector. ii) Access and equitability. All products of benefit should be made easily accessible to the general public. In this regard, strict measures should be continuously enforced to protect the public. Intellectual property and patent rights should be upheld and respected to insure economic benefit accrues to honest medical practitioners and researchers. Reports from UN (UNCTAD and GATT), have indicated that about 33 percent of drug products in the OECD countries are derived directly from higher plants; most of these are tropical plants growing in equatorial countries. However, these countries get very little benefit from the financial gain that accrues from the exploitation of these natural resource scooped up from their backyard. iii) Authenticity. All products put for human consumption should be made up of what it said to contain. This is important because most often the concoctions contain varied and unnamed components. iv) Safety of the products has to be assured by determining the pharmacological, toxicological and clinical profiles. Hence, there has to be national surveillance systems to monitor and evaluate adverse effects of these products. The myth that herbs are natural and so have no side effect is wrong as the uncontrolled use of medicinal herbs can cause strong side effects; kava-kava, used traditionally among pacific Islanders for a calming tea, were sold in concentrated forms in Europe and caused liver damage to users. v) Efficacy of these products has to be assured. vi) Rational use. This is to be guaranteed by qualification and licensing of providers, proper use of the products of assured quality, good communication amongst practitioners, provision of scientific information and guidance for the public. 6. Conclusion. Cameroon is endowed with human and material resources that can provide sound alternative care that meets the proposals of proponents of modern primary healthcare. If Alternative healthcare providers work in collaboration with modern medicine providers, this would halt the problems of quackery, corruption and confusion. At the same time strengthening Alternative healthcare locally is the surest means by which Cameroon can benefit from partnership with foreign healthcare provision. The benefit to the people would be enormous. If this is not properly done, then Cameroon’s alternative healthcare terrain will continuously be polluted by trick-stars, who rob the health sector of the Cameroonian ingenuity, abundant resource of herbs and economically important plants. Bibliography Cassel, E.J., The nature of suffering and the goals of medicine. Newyork; Avon;1994 DFL newsletter 1993. traditional healers. Ivan,A.M. Herbal medicine, intellectual property right and industrial developing countries: socio-economic, ethical and legal implications. Cultural heritage and contemporary change series II, Africa, Vol 5. Lantum, Daniel. Traditional medicine-men of Cameroon : the case of Bui Division: a socio-demographic and epidemiological profile. Yaounde: Public Health Unit, University Centre for Health Sciences, University of Yaoundé, 1986. • Mariah, G.H. Annals of internal Medicine 1998. 128: 1029 – 1034 • Ministry of economic affairs and planning, Republic of Cameroon: 1981. Fifth five-year social, economic and political plan (1981-1986). WHO 2002. Traditional Medicine strategy 2002- 2005 WHO 2001. Legal status of traditional medicine and complementary alternative medicine; A worldwide review. Copyright: All Rights Reserved. This article should be referenced, in case of usage, as: Ngwa, V.C., (2003), "Non-Conventional Healthcare Practice in Cameroon: How Safe?" Cameroon Development Project, Discussion Paper No. 20/2003, Centre for Independent Development Research, Cameroon.