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Medicine and culture

Travellers who frequent the Nigeria-India route on any of the India-bond flights from the Murtala Muhammaed International Airport, Lagos will not fail to notice an intriguing phenomenon, namely, the large number of sick Nigerians travelling to India for medical treatment. The calibre of people cuts across all sectors of the society: Higher and lower classes, young, old, male, and female, rich, poor.

One thing is common to these categories of people: each of will spend between $25,000 and $50,000 on each trip. It is also worthy of note that majority of these ‘medical tourists’ depart the Lagos airport unaided on their two feet and usually returned a month or two later with four legs, that is, on wheelchairs. This is usually as a result of very harsh treatments often involving high doses of chemotherapy and high-risk surgeries with their attendant complications. Many of them die three to four months after returning home.  Some survive for six months to one year after returning home (these group of survivals continue to visit their Asian doctors every three months for expensive check-ups).

It is reported that over 5, 000 Nigerians travel to India and other countries monthly for medical treatment.  India earns over $260 million from medical tourism from Nigeria alone. This throws up serious questions: how effective is modern medicine? What is it about India hospitals and Indian health systems that attract Nigerian medical tourists? What makes the India health system better than and different from the Nigerian health system? Could it be better trained personnel, better equipment or better infrastructure?  Or is it a part of Nigerians’ preference for anything foreign?

A study of the history of medicine in Europe shows that medicine and culture are inseparable. In fact, some scholars have demonstrated that Medicine is, in fact, as much a culture, as it is science.  A study of the British National Health Service (NHS) shows that the NHS is not just about Medicare but an integral part of the British culture. The health system in a particular country reflects the health beliefs, illness behaviour, personality, worldview and cultural values and development of that particular country.  Medicine does not exist in a vacuum. Medicine exists in a particular context.  Healthcare; health policies, treatment decisions are all contextual issues, and only makes sense when studied from its particular context.

The practice of medicine differs from culture to culture. In Britain, doctors give fewer tests, less medicine and lower doses.  Germans use six times the number of heart drugs as the French or English, although the three countries have similar rates of heart disease. France’s medical community prefers to focus on the ‘terrain,’ or the vitality of the body, and choose therapies and treatments to strengthen the terrain. The French choose gentle therapies, such as natural medicines, nutritional supplements, and rest to restore the terrain. When they do use pharmaceuticals, they choose lower dosages and shorter courses (five days instead of 10). This orientation toward shoring up the terrain has put French scientists and physicians in the lead in fields such as immunotherapy for cancer and AIDS.

In the United States of America, the emphasis is on aggressive treatments using high-tech equipment with special focus on surgical interventions. The American attitude is to view disease as a hostile invasion by foreign bodies, whether viruses or bacteria or whatever, and then declare war on the “invader.”  American doctors perform more diagnostic tests than doctors in France, Germany or Britain. They prefer aggressive surgery to drug treatment, and when they use drugs, they are likely to use higher doses and more aggressive drugs. An American woman has two to three times the chance of having a hysterectomy (a surgical procedure to remove a woman’s womb) as her counterpart in England, France or Germany. Over 60 per cent of hysterectomies in the US are performed in women under forty-four.  Many American doctors consider it routine to perform hysterectomies for women around the age of forty, especially if there is any slight pointer to cancer.  In Nigeria, most women, even of menopausal age, would consider a hysterectomy as the very last resort, while some don’t even consider it as an option at all, even under pain of death. Tampering with the womb for any reason is considered a taboo by many Nigeria women. A simplistic explanation is to regard it as religious naivety. But the matter is far too complex to be explained away by religion alone.

Medical practice is also influenced by the way doctors are remunerated in various countries. Since prices of medical procedures are fixed in advance, the only way a French doctor, for example,  can increase his income is by performing more services. Therefore, if a French doctor wants to double his income, he takes out as many appendixes as possible, but if an American doctor wants to double his income, he doubles his fees. American doctors, whose insurance companies would require them to perform a caesarean section after fibroid removal, are more prone to remove the uterus than French doctors who have no such pressure. In Nigeria, majority of doctors who work in government hospitals also have their own private clinics. This practice is outlawed in Europe and America as well as in Nigeria.  The difference is that while this law is dutifully enforced in other countries, in Nigeria, it exists only on paper. This has encouraged doctors to refer many of their patients to their own private clinics. Majority of non-complicated surgeries in Nigeria are therefore done in private clinics owned by government employed doctors.

Different organs are looked at as important by different cultures. The French place great stress on the liver, its ability to process food and to regulate the body, while the Germans focus on the heart. A beautiful woman in French culture has slim body, is tall, and has straight, smooth legs, beautiful skin and medium-sized breasts. A beautiful American woman is expected to have large breasts. For the German, the heart is all that matters. In Eastern and Western Nigeria, being moderately fat is considered beautiful and attractive in a woman.  Like the Nigerian, the French value fertility and so would do everything possible to preserve it. This explains why  French doctors would use a hysterosalpingogram (an infertility test that shows whether both fallopian tubes are open and whether the shape of the uterine cavity is normal) instead of the D&C (Dilation and Curettage) that German, English and Americans use to diagnose conditions because they are afraid of adhesions from surgery that might impair fertility.

American doctors do excessive hysterectomies that would be considered unwarranted in England, France and Germany. While French and German doctors would do lumpectomies (surgical excision of a tumour from the breast with the removal of a minimal amount of surrounding tissue), American doctors are likely to go for radical mastectomies (surgical removal of one or both breasts).

‘Overdosed America’ is the title of a book by John Abramson, an American Medical practitioner, that laments how the profit motif has taken over healthcare in America, and of course the culture is fast spreading to other parts of the world, including Africa. Abramson observed that new normalsare frequently adopted for blood pressure, cholesterol levels and blood sugar based more on market forces than on science, while new diseases like osteoporosis, erectile dysfunction have been developed. Too fat, too thin, too sad, too happy… whatever the problem is, Biotech is developing a vaccine or a pill to cure us. The world we live in is a world where all our worries can be medicated away.  Loss of a job, the death of a loved one, or even a pet – is often treated with antidepressants that are otherwise indicated for major depressive disorders. Biotech not only treats our diseases, but it often invents diseases and then goes ahead to provide the medication to cure its invention. The American Psychiatric Association will soon recognise being a ‘shopaholic’ as a clinical disorder. At Stanford University, trials held on the SSRI anti-depressant Citalopram concluded that the drug was a ‘safe and effective treatment for Compulsive Shopping Disorder.’

In 2011, clinics to treat Internet addiction have opened in the US and China. What were once considered normal human events and common human problems—pregnancy, birth, aging, menopause, alcoholism, and obesity—are now viewed as medical conditions. For better or worse, medicine increasingly permeates aspects of daily life. Intense adverts by pharmaceutical companies ensure that patients put pressure on their doctors to prescribe drugs that are often useless.   Science-based lifestyle changes are all-too-often under-utilized in patients at risk of heart disease, cancer, hypertension or diabetes in favor of using medications as a first-line approach.

It is not true that people patronise traditional/alternative medicine because they are too poor to afford biomedicine. Thirty-nine per cent of French doctors and 20 per cent of German doctors prescribe alternative medicines. More than 40 per cent of British general practitioners refer patients to alternative medicine practitioners, especially homeopathic doctors, and 45 per cent of Dutch physicians consider alternative remedies effective. Recognising that over 50 percent of its population is using homeopathy, herbal medicine, and other natural healing therapies, Canada established the Office of Natural Health Products in March 1999. The right to choose one’s preferred health system is as fundamental as the right to free speech and must be respected by responsible governments.

If the Nigerian government is truly serious about improving health care services, it must give the required support, recognition to traditional/alternative medicine and set up appropriate regulatory policies in place to ensure standards. The current, imported biomedical system of health is inadequate to cater for the health needs of Nigerians. It is time government partner with reputable alternative medicine research institutions so as to improve the health of the nation.

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