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BMJ 2002;324:688-689 ( 23 March )

Editorials

Africa can solve its own health problems

But first, the continent must reorder its priorities and commit to distributive justice

See also Papers p 702

On the evidence of such archaeological finds as Lucy, the australopithecine female unearthed in Ethiopia's Hadar region, Africa is the cradle of the human race. Africa was also home to notable ancient civilisationsthe Egypt of the Pharaohs, the Ashanti Empire of the Gold Coast, and the Zimbabwe settlements in the south. Given such a head start, it is ironic that Africa should now find itself at the bottom of the ladder in terms of human development. Most of the countries in sub-Saharan Africa lag far behind other developing nations with respect to critical health indicators such as maternal and infant mortality and life expectancy.

Granted, Africa's legacy of particularly exploitative colonial occupation by European powers is partly to blame. However, Africans themselves must bear the responsibility for failing to create an enabling environment for better healthsafe water and sanitation, secure supply of food and nutrition, education, and higher status of womenin the period since the continent's political emancipation that began with Ghana's independence in 1957.¹ Instead, many countries have seen both opportunity and resources squandered on political adventurism, civil wars, misguided macroeconomic policies, and greed.

Nevertheless, with sufficient will, commitment, and vision, and by making the right choices, Africa can successfully address its own health challenges and start to contain the morbidity and mortality from diarrhoeal diseases, childhood infections, parasites, and maternal and perinatal morbidity, as well as emerging and re-emerging infections of HIV, malaria, and tuberculosis. Africa's health challenges are not insurmountable. In most cases, the solutions are straightforward and inexpensive, requiring only that the right political choices be made.

The World Health Organisation has identified poverty in Africa as "the single biggest threat to health."² And in an unpublished speech to Kenya's Medical Research Foundation on 19 January 2001, Britain's minister for the Department for International Development, Baroness Amos, warned that "in the short term and in the long run, African governments, leaders, and individuals will need to exercise more leadership, set agendas, and mobilise far more resources, for a sustained response to lift people out of poverty."

Africa's top priority must therefore be to grow the economy, which in the view of the World Bank means buying into the global economic movement. David Dollar of the World Bank cites the example of Vietnam, where the proportion of the population in poverty fell from 75% in 1988 to 37% in 1999 as the country "opened up to foreign trade."³ This view is not universal, however, as has been evident in the "anticapitalism" protests spanning the globe from Seattle to Genoa. Certainly, globalisation has been responsible for crises in banking and currency, steep rises in poverty rates, and widening income inequalities in many countries.⁴

While African countries cannot escape the global movement, they must embrace it with the necessary circumspection. Two harms of globalisation come to mind. The first is the use of Africans to test drugs from which they will never benefit, either because the drugs are too costly or because they are designed to treat conditions that largely affect industrialised nations.⁵ The second is the global proselytising of first world values that are detrimental to Africa. The ban on dicophane (DDT)a cheap and highly effective weapon against malariabecause it was thought to be harmful to US bird species cost millions of African lives, whereas no African has ever died from the normal use of dicophane.⁶

The mere accumulation of national wealth is not sufficient to deal with poverty as a health risk. Africa must commit to equity and economic distributive justice in order to address national health needs. With this approach, the poor Indian state of Kerala has achieved health indicators almost comparable to those of the United States despite its per capita income being 99% less and its spending on health being $28 per capita compared with $3925 in the United States.⁷ China, Costa Rica, and Sri Lanka have made similarly impressive gains.⁸

This means that African countries must address the highly unequal access to personal health care that exists between rich and poor, between urban and rural populations, and between ethnic groups. They must develop coherent and equitable national health systems, redirecting resources from curative care in urban hospitals using expensive high tech equipment to primary and preventive care encompassing immunisation, nutrition, and other elements of an enabling environment for better health.

Finally, Africa must look for what South Africa's President Thabo Mbeki, speaking of HIV and AIDS, characterised as "African solutions to African health problems." To this end, Africa must revive its universities, once heralded as beacons of progress and hope. In the late 1960s and early 1970s African medical schools such as those at Ibadan (Nigeria), Accra (Ghana), and Makerere (Uganda) were counted among the finest in the developing world, engaged in the basic and applied research of typically African health problems. Only when a critical mass of African researchers working on African soil has been restored will Africa begin to generate new knowledge relevant to its most pressing health problems.

Daniel J Ncayiyana, editor, South African Medical Journal. 

Vice Chancellor's office, ML Sultan Technikon, PO Box 1334, Durban 4000, South Africa

1.	World Bank. Better health in Africaexperience and lessons learned. Washington, DC: World Bank, 1994:29.
2.	Brundtland GH. Address to the regional committee for Africa, 48th session, Harare, Zimbabwe, 31 August 1998. www.who.int/director-general/speeches/1998/english/19980831_afro.html (updated 15 May 2001).
3.	Dollar D. Is globalisation good for your health? Bull World Health Organ 2001; 79: 827-833[Medline].
4.	Cornia G. Globalisation and health: results and options. Bull World Health Organ 2001; 79: 834-841[Medline].
5.	McDonald R, Yamey G. The cost to global health of drug company profits. West J Med 2001; 174: 302-303[Full Text].
6.	Lieberman AJ, Kwon SC. Facts versus fears: a review of the greatest unfounded health scares of recent times. New York: American Council on Science and Health, 1995.
7.	Thankappan KR. Some health implications of globalisation in Kerala, India. Bull World Health Organ 2001; 79: 892-893[Medline].
8.	Halstead SB, Walsh JA, Warren KS. Good health at low cost. Conference report. New York: Rockefeller Foundation, 1985.

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