Taking the Temperature of Eritrea’s Health

What is the state of healthcare in Eritrea? What is the “before” and what is the “after”? What are the objective ways to measure if the health of Eritreans is progressing, regressing or at a standstill? Is Eritrea as fit as a fiddle or as pale as death? What are the bitter pills we must swallow? What are the physical, mental, social, emotional, and spiritual health of Eritreans like, particularly the post-independence generation? We have just what the doctor ordered: Dr. Bereket Berhane Woldeab gave his diagnosis in a long two-part audio presentation at EMDHR Paltalk Room on December 23, 2016. This is a partial translation of his presentation; the original, in Tigrinya, is attached below:

History of Hospitals in Eritrea:  During the British Military and Emperor Haile Selasse administrations, 5 hospitals were built in Eritrea.  By 1991, at Eritrea’s independence, there were 16 hospitals (most of them in Asmara); 4 medical centers, and 106 health stations, which is the lowest form of healthcare.  By 2010, based on the report provided by the Ministry of Health, there was 170% increase in healthcare.  Hospitals increased from 16 to 28; health centers from 4 to 63; and health stations [from 106 to] 246.

Access to healthcare: In 1991, 40% of Eritreans had to travel 10 kilometers to access healthcare–hospitals, medical centers and health stations.  Based on the 2010 study, 60% of Eritreans can access healthcare–from one of the healthcare facilities–within 5 miles. This is a significant change.

Capacity Building: We can categorize healthcare professionals as skilled and unskilled.  From a medical doctor all the way down to a nursing assistant and drug dispensers.  The others would be administrators.  I will focus on the skilled professionals.  In 1991, the estimate of skilled healthcare professionals was around 250.  This was based on studies conducted in 1992 and 1995, as well as one done before the fall of the Derg era in 1989-90.  The quantity of healthcare professionals increased from 250 in 1992 to 1,350 in 2009.

Rates and Ratios:
(a) Mortality rate of under 1 year of age: decreased from 150/1,000 to 22/ 1,000, based on report prepared in 2010.  What this means is 1/24 of Eritreans die before they turn 1 year old.  [Editor: Well, actually, it is 1/44]

(b) Mortality rate of under 5 years of age: 1/16 of infants die before their 5th birthday. If one compares this with the independence era [1991] and just after, it is one where big changes were witnessed.

(c) Maternal mortality ratio: In 1991, this was 1,700/100,000.   If we look at the 2013 data, it is 380/100,000.  And this is very, very admirable—if true.  Related to this, the comparable figures for women who give birth in a medical setting is something that should be commended.

(d) If there is one thing that hasn’t shown any change, it is the nutritional status of infants. Not just lack of progress, but regression.  And we measure this by: height-compared-to-age and weight-compared-to-age.  One is called stunting and the other is wasting.  As of now, 50% of Eritrean children are stunted and wasted, and of those 39% are extreme.

(e) Referencing the Millennium Developmental Goals (MDGS),when it comes to malaria, in those areas where it is prevalent, 33% have mosquito nets; HIV prevalence rate is 2.3%. The prevalence rate is 1.13% for females, and 0.5% for males.

(f) Life expectancy has increased to the 60s.

Now we have to be able to critically assess what’s reported.

Let’s begin with the Millennium Developmental Goals (MDGS.)  They are not goals set in Asmara but Geneva and other international centers, and imposed on all countries, all members of the international community.  MDGs are developed with the common understanding that improvements in health are influenced by other factors– economic, political, policy-related, etc.  So if we look at MDG: 1, it deals with poverty and hunger.  It is predicated on the understanding outlined in 1989 that public health policy is based on child health policy.  As I mentioned previously, the situation of under-5-year-of-age infants, the stunting and wasting is very worrisome, approaching 50%.

One cause for skepticism in all these figures is that there has never been a census taken in Eritrea before or since 1991.  In my research, I looked at census of the “natives” (indigenous Eritreans) taken by Fascist Italy in the 1930s, and it was around 450,000.  In 2002, 2005 and 2010, there were projections made from a small sample size.  Excepting that, there hasn’t been an actual census taken.  And until one is published, [because all the figures published are ratios and rates], we should look at them with skepticism.

If that is the case, why do different countries and the UN accept them as facts? This is because reports are the responsibilities of sovereign countries: their governments prepare and publish, the others [UN, other countries] have no responsibility other than to accept.  So long as there are no demographics, one has to treat these figures with suspicion.

To conclude, the increase in the capacity of healthcare is extremely satisfying.  However, one has to look at these facilities–hospitals, clinics, health centers–and consider this: unless they are staffed properly, have adequate equipment and medicine, it doesn’t amount to much.  Based on conversations with people coming from Eritrea and external research, we can conclude that the current state of these facilities is dysfunctional.  Why?  Because there is lack of human resource and maladministration.

As an example, if we reference one of the factors I cited, human resources development–something very sad, shocking and worrisome is the case of an institution that the government–and we as well should be–is upbeat about: Orotta Medical School.   There is a six-month long study of the institution that we can cite as reference, as an eye-opener.

Based on the initiative taken by the late Saleh Meki [former Minister of Health], the school was opened in 2003-04.  Let’s look at the developments since.  Between 2009 to present, 112 graduates of the school have left the country.  From the first batch: of the 32 graduates, 21 are not in Eritrea.  From the second batch: of the 32 graduates, 20 are not in the country.  From the third batch: of the 39 graduates, 20 are not in the country.  From the fourth batch: of 49 graduates, 26 are not in the country.  It continues like that, and I have all the figures and names.  Similarly, from the dental school, of 10 graduates, 5 are not in the country.

Again, from 2009 to present, if we take a look at veteran physicians–veterans who are experienced, who know our society, who know all the varieties of illnesses…you can estimate the damage to the population when you lose one such physician.  Between 2009 and now, we have lost 38 veteran physicians who have left the country, bringing the sum total of physicians who have left the country to 150.  This doesn’t count the usual brain drain of people who don’t return from an assignment: what we are witnessing is not normal, never-been-seen-before development.

I interviewed about 20 of them, to inquire why they left.  There are some fundamental things a government has to do to retain people.  Most of them didn’t raise the issue of salary.  What else? Professional development training; job dissatisfaction; lack of supplies, burnout.  Opportunities for advanced education don’t exist: they are closed.  A few mentioned salary, improving their lifestyle.  If you recall, in December 2009, the government–via one of its customary proclamations–closed all the private clinics.  Perhaps this is related to the migration of the veteran doctors, in my view.  In 2011, all the articulation agreements that Orotta Medical School had with American and other institutions [of higher learning and hospitals] were voided, denying opportunities for graduates to take advanced classes.  This disheartens people to the point of almost pushing them out of the country.

In conclusion, Orotta Medical School, the institution we were hopeful about, is one that has graduated 100 physicians of whom 50 have left the country.  The consequences and magnitude of losing such skilled people, after 8 years of investing in their education, is not something that requires much analysis.  Beyond this, about a month ago, I was in Northern Ethiopia visiting the refugee camps, and I met 3 recent arrivals, not graduates, but who had dropped out from medical school in their 3rd, 4th and 5th year.  We can describe this as human resource mismanagement…

If you are claiming success in health, what is “health”? In 1948, the World Health Organization [WHO] described health not as presence or absence of illness.  Health is more comprehensive including body, mind and social wellness.

This is the true measure, using WHO standards: body, mind, social, emotional and spiritual wellness. Let’s use these standards to assess the health of [the post independence] generation of Eritreans.

Healthy Body: These we have mentioned above: under-1-age mortality rate; under-5-age mortality rate; maternal mortality ratio, and others.

Healthy Mind: Everyone should have full right to think, to inquire to their full potential.  This is greatly determined during pregnancy and shortly after the child is born.  Two years ago, UNICEF and other institutions released a report based on their research [which concluded that]  the first two to three years of infants lives, and the support they get–nutrition, other factors–greatly influence the kind of life they are going to have.

Social Health: We measure social life by one’s ability to form relationships.  They are things like growing up with your family; ability to get married; to collectively express sorrow in moments of grief; and to express joy with others in moments of happiness.

Emotional Health: Human beings have things that trigger their anger, happiness, sadness. If one can express anger on issues that cause anger; can shed a tear, in matters that cause sadness; can laugh when happy, then that person is said to be emotionally healthy.

Spiritual Health: when mankind is given the right to worship–be it religious or cultural–then we can say there is spiritual health.

Now let’s take a look at all five factors and assess the health of the new, post independence generation.  They are deficient in all.  And this is where the great failure of the government shows.

Looking at the health of children… WHO does not just look at presence of absence of measles and malaria.  The same five criteria above are used with this one more supplement: importance of families.  From the nuclear family, to the extended family, to the community, the neighborhood, the school the child attends.  If all of these are met, then children can meet their potential.  Let’s ask: what is the situation Eritrean children are in? Almost 50% of Eritrean children are being raised by a single parent: the mother.   Nearly 17% have neither parent.  And as I mentioned previously, using age-height and age-weight ratios, almost 50% of the children suffer from stunting or wasting.  How this will impact the child’s adulthood has already been mentioned….