I. SUB-SAHARAN COUNTRIES

The geographic region of sub-Saharan Africa includes all the African countries immediately below the Sahara Desert, together with all the associated island states but excluding the Republic of South Africa. Although the latter is within the region, it is excluded from this text in view of the heavy influence that apartheid exerted on indigenous African cultures. All the countries considered are bound by the Tropic of Cancer on the north and the Tropic of Capricorn on the south. In addition to a multitude of indigenous languages, the majority of the countries are either Anglophone or Francophone; five are Lusophone (Portuguese-speaking).

Medical ethics in sub-Saharan Africa is extremely complicated and cannot be considered homogeneous in any sense. This is because the vast geographic area (almost 23 million square kilometers, or about nine million square miles) contains forty-three independent countries with innumerable sociocultural groupings. Many of the countries are nation-states only superficially, since their borders enclose ethnic groups that have little in common with their fellow citizens, being more closely affiliated with groups in other countries. Quite apart from the matter of indigenous cultures, these countries were under the domination of European colonial powers that sought to impose their cultures upon local cultures. Some countries gained political independence only in the 1980s, and in some supposedly independent countries (Angola, Mozambique, Sudan) civil strife based on ethnic differences has raged throughout most of their independent period. The interaction between an externally introduced culture and a local one is more complicated in the field of medicine than in any other. The differences in urban-center development in East Africa and West Africa demonstrate the role that colonial power had in influencing cultural and ethical values (Larson).

Traditional and Scientific Methods

Some of the countries have had contact with scientifically based European medicine for less than 50 years, and others for little more than 100 years. The development of medical ethics in all the African countries has therefore tended to follow the existing European ethical values, principally those of France and Great Britain, the two dominant colonial powers. European medical professionals, faced with traditional African medical practice, took the position that all such medical practices and values, as well as their practitioners, were bad. Traditional African healers were considered no more than quacks and deceivers and therefore were either ignored or actively persecuted. Even the traditional midwives or "birth attendants," as they are now known, who from time immemorial have provided help to women at a most difficult time, were looked upon with disfavor. To a certain extent such attitudes were underwritten by the beliefs and practices of the colonizers' religion, Christianity. Since much of traditional healing relied on the intervention of gods and spirits, which Christians found abhorrent, the practice of traditional healing was strongly discouraged. Furthermore, European medical ethics required that European doctors not associate with practitioners whose training and beliefs differed from their own.

With the rise of black consciousness and the acceptance of the notion that blackness is not a sign of inferiority, African peoples have begun to reappropriate the medical knowledge gained over centuries by traditional medicine and medical practice. In some countries laws have been passed recognizing traditional medical practice as legal and effective. This process has been very slow. Many African medical schools still do not offer any instruction in traditional medicine, and where interest exists, it is only at a research level. Financial grants have been made for research into the methods and preparations of traditional medicine. In a few instances medical scientists are actively involved with traditional practitioners.

This new collaboration between traditional and imported medical practice is likely to be furthered by the indigenization of African churches and the improvement of the quality of their leadership. Previously, priests and ministers in the majority of churches had been inadequately trained, and they tended to assume a patronizing approach to their congregants. Now, a growing number can be considered well educated; some can even be viewed as theologians who are able to help formulate the churches' views on subjects of such crucial importance as the conflict between traditional and modern medical practice. Medical professionals in the majority of countries now feel relatively free to develop new ways of practice and to work with traditional birth attendants, herbalists, and other healers without fear of losing either the respect or the comradeship of colleagues in Europe.

Traditional and Western practices are seeing crossover training in the areas of psychiatry, childbirth, and grassroots education. Much of traditional medicine touches on the realm of psychiatry. Involvement of traditional practitioners in psychiatric treatment makes for a more humane treatment and much better integration of patients into society (Lambo). Among other efforts that may be cited is the involvement of the University of Ghana Medical School in training programs for traditional birth attendants. In many countries the medical schools (Makerere University in Uganda, University of Nairobi in Kenya, and University of Yaounde in Cameroon, for example) are striving to identify relevant practices within their own societies, such as use of peer groups to educate members of their societies on health-related issues. These medical schools are, therefore, embarking on programs that identify and preserve traditional practices considered valuable (Jelliffe and Bennett). In these programs, traditional practices considered harmless or beneficial are to be permitted, and those practices considered truly harmful are to be eliminated.

Standards for Medical Practice

Most English-speaking countries have general medical councils or boards responsible for registration, accreditation, and supervision of medical practice. In most of these countries the boards of control are generally quite distinct from the ministries of health (Kenya Government). Many of these medical councils or boards, however, have fashioned policies more responsive to western European norms and needs than to African ones. These boards have had little time to devote to the development of ethical guidelines relevant to social and cultural conditions peculiar to life within African countries. Some principles remain fundamental, however: Privacy of the patient is respected, and so is confidentiality, although here and there disclosure is required by the government for various reasons, including payment for medical service, granting of sick leave by employers, and mandatory registration of births and deaths.

Healthcare Service

There are very few scientifically trained medical personnel in Africa. The ratio of scientifically trained doctors to population ranges from 1:3,000 in such better-off cities as Dakar (Senegal), Accra (Ghana), and Nairobi (Kenya) to 1:200,000 in some poorer rural areas, such as most of the Northern Region of Nigeria and all of the immediate sub-Saharan countries including Mauritania, Mali, Burkina Faso, Niger, and Chad, which are sometimes referred to as the Sahel. There are countries within which there may not be a single specialist in any recognized field of medicine. This immediately raises the issue of what kind of medicine is most suitable in such conditions.

European medicine has developed and gained the reputation of being "one-on-one" medicine, and it also has concentrated more on curative than on preventive medicine. In Africa, on the other hand, the practice of one-on-one medicine, if it is accepted as the ideal, means excluding 80 to 90 percent or more of the population, who have no access to Western-oriented medical facilities. Such medical practice also places an inhuman load on the few medical practitioners and quickly reduces them to no more than purveyors of drugs and injections. Fendall sees this as the "quantity versus quality" dilemma, although not all agree with his view.

Doctors in Africa are now being asked to view their role in light of certain priorities—the first being promotive and preventive health services and the second being curative—in terms of individual patient treatment in offices or hospitals. In attempting to respond to the first priority, many have pointed out that not much can be done until medical practice is so arranged that the community is both the consumer and the provider of its own healthcare. This can be done only if delegation of healthcare to nonphysician personnel, such as traditional birth attendants and community leaders, is done on a basis of genuine need. The debate will continue, but almost all the new medical schools have agreed that doctors' training should be responsive to the needs of the community and to the organization and priorities set by ministries of health.

Many African countries depend on the use of paramedical personnel in the running of health services at the level of primary healthcare. Paramedics are often the only healthcare personnel available at this level. They include clinical officers, laboratory technologists, public-health technicians, environmental health officers, and various kinds of nurses. They are usually trained at medical training colleges, which are non-university, diploma-awarding institutions established in countries including Zambia, Kenya, and Tanzania. Apart from the nurses, who take an oath at graduation, paramedical personnel are not subject to any ethically binding oath. This cadre of personnel has on occasion been the source of breaches of confidentiality.

Pharmacies and pharmacists, too, have presented new dilemmas to medical practice in Africa. The regulation of the drug supply has been the prerogative of the ministries of health and their relevant licensing bodies. In keeping with the increased number of university-trained pharmacists, there is increased licensing of private pharmacies, especially in Zaire, Kenya, Cameroon, and Nigeria. Pharmacists regard themselves as trained "doctors" and dispense drugs without prescription, including drugs that have previously required doctors' prescriptions. Pharmacies also may dispense inactive drugs or drugs that have no relevance to the patient's illness (World Health Organization, 1992).

The Ethics of Educating and Remunerating Doctors

Medical education has had to contend with the issue of "excellence versus quantity" in the training of doctors. Most African medical schools have felt it necessary to enroll students of the highest possible scientific caliber and to train them to internationally accepted standards. (These students are chosen based on their national high school final examination results.) The result has been that very few doctors can be graduated in any given year; but much more important, in many countries the best and sometimes the only available scientific skills are channeled into medicine, depriving other socially important areas of potential contributors. This is an ethical issue of considerable importance. In the end, many of the doctors produced choose to become specialists who can practice medicine only where they find quite sophisticated support facilities and services. Frequently they serve existing hospital needs rather than those of preventive medicine. The frustration and wastefulness of this situation underscore one of the major ethical issues on the African medical scene.

Doctors' fees have been the subject of debate in many African countries. Poverty is a major socioeconomic problem in all the countries of sub-Saharan Africa. Civil wars, political instability, ethnic violence, drought, and famine have transformed millions of already poor individuals into refugees who have fled across borders. In the midst of extensive poverty, charging fees for care raises serious ethical questions. In most of these countries, physicians are employed by the government and are not supposed to charge fees for their services. However, government pay schedules have not kept up with the cost of living, and many government doctors engage in private practice to supplement their salaries. In the late 1980s, the Kenya Medical Association considered fee schedules that would charge standard amounts for various services, without waivers or reductions for the poor. Objections were raised, and the schedule was not adopted. In Ghana, attempts have been made to adjust doctors' salaries to costs of living. In general, the costs of physicians' services, drugs, and hospitalization amid such serious deprivation deserve serious ethical scrutiny.

Population, Family Planning, and Abortion

Population control as advocated in the Western world unfortunately has blurred the issues of family planning and led to a debate that should have been completely unnecessary. There are two basic concepts in family planning. The first is to regulate total family size to a level that can be comfortably maintained using the available resources. The second is to space the intervals between pregnancies in order to promote the health of both mothers and children (King). Many African countries rightly consider themselves under-populated. Some, such as Gabon, Cameroon, and the Central African Republic, want much larger populations. All feel that they need development for the benefit of their people; but with very few exceptions, they refuse to admit that curbing population growth is relevant to the need for increased development.

Unfortunately, some doctors have failed to recognize the doctor's role in articulating relevant issues in family planning. Many doctors seem not to understand the medical importance of postponing pregnancies until a woman is biologically most prepared and of helping to stop reproduction when biological factors are no longer in a woman's favor. They also fail to recognize that spacing of births—which used to be practiced in Africa based either on sexual abstinence or on a geographic separation of husband and wife—is necessary to ensure the health of both mother and child. The excessive mortality in childbirth for women fourteen to forty-five years of age has not been fully appreciated by most of the medical profession in Africa (World Health Organization, 1975). Even where this situation is recognized, continued adherence to inappropriate laws and practices imposed from Europe often means that family-splanning services are withheld from the majority of the population in need. The Catholic church, through its influence in the French-speaking countries, did much to prevent medical leadership in family planning. French laws passed in 1920 prohibiting contraception are still on the statute books of many French-speaking African countries, despite their repeal by France and Mali in 1972 (Wolf).

In the field of contraception, the major ethical question the doctor faces is, therefore, whether he or she should encourage free provision of contraceptives by nonmedical personnel, knowing that Europe and the United States, which are the sources of these supplies, require that they be dispensed almost exclusively by doctors. The doctor must weigh the possibility of breaking outdated laws against the results of withholding such supplies from populations that have no other source.

Other serious ethical questions are raised in providing contraception to women who are not married, according to the traditional norms prevailing in their locality, or who want to practice contraception without the knowledge of their regular partner. Yet so tenuous are some of the marital relationships, so difficult is it to get some husbands into a hospital or family-planning clinic, that insistence on consent by both parties might, in the end, do an injustice to the woman. Physicians must resolve this ethical dilemma within their own national frontiers.

African societies generally do not accept abortion because they value highly the continuity of lineage; the unborn child, for example, may be a reincarnation of an ancestor. However, it would be untrue to say that abortions were not known in Africa before the arrival of white colonizers. In many African cultures, pregnancies resulting from taboo relationships or from adultery are terminated generally by women and the men are kept in the dark.

The question of abortion is now debated seriously. Many of the abortion laws in Africa are based on those of England and France, which repealed them in 1967 and 1974, respectively. However, in the majority of former British and French possessions the old laws are still on the statute books. The increasing number of illegal abortions, with their consequent mortality, morbidity, and sterility, have still not prompted the collective conscience of medical practitioners to have the laws reviewed. Zambia did review its laws and amend them in 1973, but stipulations within the new law, particularly one that the approval of two medical practitioners is required, make it unlikely to serve the majority of those in need. The Africa Regional Conference on Abortion held in Accra, Ghana, in 1973 agreed to call for a review of the laws, but little has been done.

The doctors' dilemma regarding abortion is twofold. Despite the law, increasing numbers of women risk their lives by recourse to back-street abortionists. At the same time there are so few doctors to respond to such a wide range of needs that to make abortion laws more liberal may mean increasing the load on doctors still further. Given these problems, it is difficult to understand the view of some doctors in African countries that education, information, and services for fertility regulation should be limited.

Healthcare and Research in the Era of AIDS

The acquired immunodeficiency syndrome (AIDS), first recognized in 1981, has had the most profound impact on healthcare in Africa. Major concerns in healthcare provision are related to confidentiality, informed consent, counseling, research, drug therapy, serotesting, and care of the sick.

When AIDS was first identified as a major public-health problem and a rapidly spreading epidemic in Africa, many African governments reacted with violent denials. This behavior, which was attributed in part to the claim that AIDS originated in Africa, received support from some physicians and ministries of health. The early rapid spread of AIDS in Africa was partly a result of the fact that it was not acknowledged as a major public-health problem and thus received only slow governmental response (Ndinya-Achola).

Confidentiality and counseling are two components in AIDS-control programs that have received, at best, lip service in Africa. Counseling is an extension of preventive educational campaigns. At population levels these campaigns use information, education, and communication as their basic tools, and public-health officials as their main promoters. Counseling deals directly with the individual. The personal interaction between counselor and patient enables individuals to better understand their personal risks, to make informed decisions, and to take appropriate action.

Under ideal conditions, counseling is provided on a one-to-one basis and each case is dealt with on its own merit. Counseling also involves providing facilities that respond to the physical and emotional needs of the affected individuals and their loved ones. In Africa, AIDS counselors began to be trained in 1988; the needs of the society far exceed the number of counselors available. Much of the counseling that is provided is done by individuals who have no training. In many instances it amounts to informing an individual that he or she is infected with the AIDS virus; the healthcare provider is faced with the ethical question of whether to withhold information about the illness because there are no facilities to cater to individual needs.

Even where conditions are adequate and counseling facilities are available, confidentiality is a major issue because some of the trained counselors are not ethically bound to keep confidentiality. In particular, confidentiality is lacking in Africa for individuals diagnosed with AIDS. Counselors, however, are not the only healthcare providers ignoring confidentiality. Information regarding AIDS diagnosis often is leaked by hospital laboratory and other care staff.

Biomedical Research

Care for those with AIDS and drug therapy are two additional areas of major ethical concern. In many African settings the diagnosis of AIDS results in patient neglect because of the stigma attached to the disease. AIDS is a stigmatized disease in Africa mainly because the earliest information linked it to homosexuality, which is regarded as antisocial behavior in many parts of Africa. After it was ascertained that AIDS was being transmitted primarily by heterosexual contact, the homosexual stigma of AIDS lessened; but then AIDS became further stigmatized because of the rapid spread among heterosexuals by means of multiple sex partners and increased promiscuity. AIDS educational programs also had the inappropriate but true message that death is the final outcome. For these reasons, AIDS has had a negative impact on social interactions. Many people fear to be associated with a person with AIDS. This fear is evident even among professionals. Nurses have been a little more ethical in their approach to care of AIDS patients than physicians, perhaps because the nurses' increased contact with the patients makes them more sympathetic to the patients' plight.

During the early years of the AIDS epidemic, researchers from all over the world quickly identified populations in Africa for epidemiological studies (Van de Perre et al.; Kreiss et al.; Piot et al.). Clinical studies on drugs and vaccines are also being done. This research brings to the fore ethical questions about biomedical research in African countries that predated the AIDS epidemic: Should Western scientists do studies on populations that may never benefit from the results? Can appropriate informed consent be obtained in cultures that have different values? These questions are much debated within Africa and abroad (IJsselmuiden and Faden). Standards of research have been improved: Some medical journals, such as East African Medical Journal, insist that proof of informed consent be provided before articles are accepted; granting agencies in Europe and the United States require local ethical review before funding is provided; and local review boards are becoming quite strict.

One of the important contributions of biomedical research in AIDS is the development of antiretroviral drugs for treating infection caused by human immunodeficiency virus (HIV), the causative agent of AIDS. Although the available drugs do not currently offer a cure, some of them have been shown to prolong life significantly. These drugs are far too expensive for African populations. The same research groups that solicited funds for epidemiologic studies should be persuaded to do the same in order to make anti-AIDS drugs affordable for African populations. The first ten years of the AIDS epidemic has had profound social, cultural, economic, and health impacts in sub-Saharan Africa. These effects, which include loss of social structure, orphaned children, reduced productivity, and severe depletion of healthcare budgets, no doubt will significantly increase over the next decade. Even if medical care or a vaccine were made available immediately, the already large number of infected individuals will continue to burden the society. Healthcare standards will be influenced by the AIDS epidemic for a long time. The decade of the 1990s is the right time for African healthcare services to review their programs and put in place relevant practices and resources without compromising their ethics in caring for people with AIDS. It would be heartening to see African countries taking a lead in the care of people with AIDS.

Conclusion

Significant improvements are continually being made in medical training and standards of healthcare throughout sub-Saharan Africa. These improvements, however, are still not matched by proportionate improvement in medical ethics. Many African medical schools' curricula do not include ethics. Where it is included, the subject is still accorded very little time (usually a one-hour lecture). In order to sensitize doctors and other healthcare personnel on issues related to medical ethics, African medical schools and medical training colleges should be encouraged to develop curricula on ethics. It may also be necessary to sensitize populations on the subject along the same lines that disease prevention has been brought to the community level through health education.

jeckoniah o. ndinya-achola (1995)

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