$Unique_ID{bob00312}
$Pretitle{}
$Title{Cote d'Ivoire
Chapter 10B.  Health}
$Subtitle{}
$Author{T.D. Roberts, Donald M. Bouton, Irving Kaplan, Barbara Lent, Charles Townsend, Neda A. Walpole}
$Affiliation{HQ, Department of the Army}
$Subject{medical
health
diseases
government
french
ivory
country
population
school
children}
$Date{1973}
$Log{}
Title:       Cote d'Ivoire
Book:        Area Handbook for Ivory Coast
Author:      T.D. Roberts, Donald M. Bouton, Irving Kaplan, Barbara Lent, Charles Townsend, Neda A. Walpole
Affiliation: HQ, Department of the Army
Date:        1973

Chapter 10B.  Health

     On the basis of estimates made from representative samplings in different
parts of the country, life expectancy in the period 1956-58 was 30 to 38
years. The birth rate during the same period was 56 per 1,000, while the
death rate was 27 per 1,000. The infant mortality rate was 146 per 1,000
live births, and it was estimated that about 50 percent of the children die
before reaching the age of 5 years because of improper care and poor health
standards.

     Modern medicine was introduced by the medical corps of the French
colonial army in the late nineteenth century when it established medical
outposts for the care of French troops and the indigenous population. Faced
with a plethora of tropical diseases which attacked the army and, after
conquest, hindered economic progress by sapping the energy of French and
native alike, the army medical corps, in cooperation with the colonial
government, embarked on a program of mass prophylaxy consisting of health
education, examination and inoculation for the known diseases and research
into the lesser-known ones. Through the whole colonial period health education
and preventive medicine received much attention. Since World War II, the fight
against endemic disease has been joined by the World Health Organization (WHO)
and the United Nations Children's Fund (UNICEF), which have provided both
funds and equipment.

     The Ivory Coast Government is fully aware of the health needs of the
country and of the importance of good health for economic development. In
1962 it was planning to establish a National Institute of Health at Adjame
to study the health needs of the country and establish a system of priorities.
It will also act as the central bureau for medical statistics, organize
training programs for specialists and for the general public in matters of
health and sanitation, set up rural health centers to act as consultation
and demonstration centers for the rural population, and operate laboratories
for the testing of water and for food research.

Prevalent Diseases

     Accurate statistical information on the incidence of the various
common diseases is lacking, because the system of medical recording is
haphazardous and inefficient and because as yet only a limited percent of
the sick come to the attention of medical authorities. Poor health is
characteristic in the Ivory Coast, as in most of Africa. Although statistics
show a continuing increase in the disease rate, this is a reflection of the
growing number of people reached by medical authorities rather than of an
actual increase in morbidity. The effectiveness of health programs is
illustrated by the steadily declining rate among the persons treated for
various diseases.

     Among the most common causes of illness are malaria, the various
dysenteries and parasitic diseases, yaws, various pneumonias and tuberculosis.
Leprosy, sleeping sickness, and venereal diseases also claim a large number
of victims. Epidemic diseases, such as smallpox and yellow fever, have been
largely controlled through mass vaccination. Illnesses are caused by the
presence, particularly in the rain forest and along waterways, of the
plethora of disease-carrying insects common throughout the tropics; by the
use of polluted water for bathing and drinking; by malnutrition, which both
causes specific disabilities and lowers resistance to every disease; and by
the low level of sanitation and personal hygiene, which creates breeding
grounds for infections and other diseases. Every cut or skin abrasion is
dangerous; childbirth is a serious risk; a mosquito or fly bite may lead to
malaria or blindness. Many diseases, fatal to a European, are endemic among
large segments of the population and claim relatively few lives, though they
weaken the whole system and shorten the life expectancy.

     Malaria is the prime cause of illness. It is a major killer of newborn
infants, and almost all Ivory Coasters contract it at an early stage of life.
For most African adults, malaria is a relatively mild disease because
resistance has been either inherited or built up during childhood but
Europeans are highly susceptible and without protective measures are likely
to contract it in an acute and dangerous form.

     The second major cause of disease is the various dysenteries and
parasitic diseases which, though seldom fatal, are seriously debilitating.
Since they tend to remain undetected by medical authorities, their serious
incidence is not shown by medical statistics. The high incidence reflects
the low standard of public health and personal hygiene since most are
transmitted by polluted water. Most common among them are Guinea worm and
bilharzia.

     Yaws, highly infectious sores associated with uncleanliness, are
common throughout the country. Over 100,000 cases were detected and treated
by mobile medical units in 1957 when the government initiated a mass
campaign to eradicate the disease.

     Tuberculosis has been shown to be almost as common as malaria in some
parts of the country, particularly among urban laborers, fishermen, and
children under 15. The dirty, close quarters of workers and fishermen are
fertile breeding ground for the disease. Since the mid-1950s the
government has undertaken systematic vaccination, with the antituberculine
drug B.C.G., of newborn infants and school children in all areas served by
a permanent medical establishment and requires periodic X-ray examinations
of all wage-earners and schoolchildren.

     Venereal disease is particularly prevalent in the crowded urban slums.
It follows yaws in the number of cases detected and treated.

     Efforts to control leprosy now reach the most remote areas and, given
the continued cooperation of those afflicted, should be brought under control
in the near future. Of the approximately 50,000 known lepers in the country
in 1962, only the most serious cases were confined to one of the dozen or so
leprosaria; the rest were treated regularly as out-patients either at a
leprosarium or at a general dispensary.

     Sleeping sickness, carried by the tsetse fly, is a major problem in the
forest region between Man and Duekoue and the Liberian border and in the
area around Agboville. In the country as a whole, however, the disease is less
of a problem than in some of the other West African countries further to the
east. Sleeping sickness may be dormant in a person for many years, sapping
his energy and lowering his resistance to other diseases, but when it emerges,
quick death is certain. The activities of the mobile health units which
treat victims in the early stages of the disease, when it is still curable,
have considerably reduced the death rate.

     The rate of blindness is very high in the Ivory Coast, as in all West
Africa, particularly in the north. The major causes of blindness are
vitamin A deficiency, river blindness (Onchocerciasis), various parasitic
infections caused by contact with polluted water, trachoma and, to a lesser
degree, congenital syphilis.

     Diseases such as smallpox and yellow fever, which for centuries were
major killers, have now been largely controlled through mass vaccination.
A massive antismallpox campaign has been operating for several years and is
designed to cover every part of the country with mobile medical units to
examine and vaccinate the population. Automatic vaccination against smallpox
and yellow fever is given to all mothers and infants who visit a maternity
center, all children who attend schools, and all wage-earners employed by
the government or one of the larger industrial and commercial enterprises.
No serious epidemics of contagious diseases have occurred since World War II.

Folk Medicine and Superstition

     As yet, modern medicine has been accepted at best by only about
one-fourth of the population, largely among educated classes in urban areas
where medical facilities are easily accessible. Three-fourths or more of the
people still rely to a greater or lesser extent on native doctors and ancient
cures and will seek medical help only as a last resort, usually too late. The
undramatic and intangible nature of modern medical practices raises doubts
in many minds about their efficacy. Among those who make use of the modern
facilities, many insist on receiving injections which they assume to be a
cure-all.

     The main reason for the continued reliance on traditional cures is a
common belief that illness and death are caused by supernatural forces and
can only be countered by other supernatural forces. Traditional medical
practitioners are usually persons believed to possess magical powers, and
their cures include the use of fetishes and amulets which are carried on the
person or displayed prominently in the home, herbal potions or salves, and
incense burning. Bleeding to let out the poison is a common practice, as is
rubbing herbs into an incision or inserting leaves, roots or bark for which
curative properties are claimed. The severe pain which results is believed
to be essential to the cure.

     The medical value of most traditional remedies is suspect. In many cases
they are unquestionably harmful and may result in severe infection and death.
A few traditional practices, however, have been shown to be useful. Most
northern peoples, for instance, have long practiced a form of inoculation for
smallpox through vaccination with pus from afflicted persons.

     Native doctors, commonly known as feticheurs, generally fall into two
categories although it is often difficult to distinguish them. Witch doctors
rely for their cures on the supernatural and on their knowledge of social
relationship in their village. They are usually priest-doctors occupying
positions of great prestige and power in the community. Herbalists dispense
actual medications based on what are considered to be scientific theories.
Their status in the community is that of skilled technician, and their skill
is usually acquired through a vocation. Many of the formulas used in
preparing the various cures are secret and can only be passed on to qualified
persons.

     A decree passed in 1947 for the federation of French West Africa
repressed the use of witchcraft and magic and the administration of any
substance harmful to health. However, it has had little real effect, and
native practitioners will continue to play an important role at least until
a sufficient number of modern medical facilities are established in all parts
of the country to effectively serve the entire population.

Medical Services

     Most medical services are provided by the national government, but a
number of missionary societies ,and private enterprises also operate medical
facilities. All are under the jurisdiction and control of the Ministry of
Public Health and Population, which is also charged with the administration
of the School Health Service and the Maternity Service; the control and
inspection of restaurants, commercial and industrial establishments and other
public places; the inspection and control of drugs and narcotics; the
suppression of fraudulent medical practices, including the supervision of
herbalists and native practitioners; and the establishment of educational and
professional standards for medical personnel.

     The primary problem of the health services has been to provide
sufficient facilities to reach the entire population and to break down the
distrust of modern medicine. Considerable emphasis has been placed on
preventive medicine in the form of general health education of the public,
mass examinations and mass inoculations for the most serious endemic
diseases. These functions are entrusted to the Service for Major Endemic
Diseases (Service des Grandes Endemies-SGE) which is a special section in
the Ministry of Public Health and Population and works closely with similar
services in other former French colonies through the Organization for
Coordination and Cooperation Against Major Endemic Diseases (Organisation
de Coordination et de Cooperation Contre les Grandes Endemies-OCCGE)
centered at Dobo Dioulasso, Upper Volta.

     Preventive medicine is also practiced in the form of improving the
general sanitation of the people. Urban areas are systematically sprayed
against insects, particularly the malaria mosquito; sewage disposal systems
and potable water supplies are being constructed in towns and villages
as rapidly as financial resources will allow; and slums are being replaced
by low-income housing. Among these costly projects, priority is given to the
construction of sanitary drainage systems and water supplies, but financial
limitations make progress slow.

     Funds for the administration of medical services come from the national
budget,local government budgets, and the French Government through its
technical assistance programs. Complicated accounting and credit arrangements
make it almost impossible to ascertain the extent of contribution by each, but
the national budget for 1962 provided CFA F2.3 billion ($9.5 million) for
current expenditures on health (9 percent of the total budget) and CFA F173
million ($0.7 million) for capital investment for health and other social
services during 1962-63. A large part of the funds for special projects in
preventive medicine and medical research comes from WHO and UNICEF.

     Since January 1962 all medical care administered by the public services
has been free of charge. Care is usually administered on an outpatient basis,
and only severe cases are hospitalized.

Facilities

     In 1961 medical facilities comprised about 6,500 beds in hospitals and
other institutions-roughly 1 for each 500 persons. This compares very
favorably with other countries in West Africa. However, almost one-fourth of
the beds were concentrated in three large hospitals in Abidjan and Bouake; the
rest of the population, particularly that in the northern and western parts of
the country, is very poorly served. The government is planning to eliminate
this disparity within the next few years by building a complete 400-bed
hospital center at each departement capital and a smaller secondary hospital
at each seat of a sub-prefecture. Six secondary hospitals were already in
operation in 1962.

     Medical centers, of which there were 54 in 1961, are located in the more
important urban centers or in areas of major economic activity. They consist
of a dispensary, a maternity clinic and a pavilion for hospitalized patients
and are under the direction of 1 or 2 fully qualified physicians, depending
on the size of the population served. The most common medical facility is the
dispensary operated by a certified nurse; in 1961, 112 were scattered
throughout the country, 31 operated by Christian missionaries. Dispensaries
operate as out-patient clinics treating routine cases and promoting health
education and maternity care Problem cases are referred to the nearest
hospital.

     Mobile medical units operated by the SGE and by the Institute of Hygiene
play a major part in providing health care for the population because they
take modern medical treatment and health education to the remote parts of the
country. Equipped with a specially trained staff and a compact laboratory,
the mobile units move from village to village systematically examining all
inhabitants for symptoms of any of the more common endemic diseases, such as
leprosy, sleeping sickness, trachoma; administering preventive drugs and
inoculations; and treating all those in need of treatment. To facilitate
operations, the SGE divided the country into sections of approximately 200,000
persons, within which units operate on a regularly established circuit
permitting continued treatment at set intervals. In 1960 about 1.3 million
persons, or 40 percent of the population, were examined and treated by one of
the units. Before the Ivory Coast became independent, the SGE (then known as
the Service General d'Hygiene Mobile et Prophylaxie) was part of a central
interterritorial service created by the French after World War I to combat
epidemics and serve the medical needs of all of French West Africa. In
addition to the medical field units, the central service also operated a
number of research institutes investigating the principal endemic diseases;
an institute of African nutrition; and a school for training the special staff
required by its facilities. Although the field units were transformed into a
national service after the territories composing French West Africa became
independent, the research institutes and the school continue to serve all the
territories as part of the OCCGE, of which all except Guinea are members.
Funds for the OCCGE come from the member countries and from France, which
provides the largest part of the money and almost the entire staff.

     Many of the commercial plantations and larger industrial and commercial
enterprises operate private medical facilities for employees and their
families. They range from first-aid stations in the charge of a nurse to
complete clinics operated by physicians. Given the great need for medical care
in the country, these facilities are of major importance.

     Information about dental services is completely lacking beyond a
government statement indicating that five dentists were included in the
medical service.

     Special medical facilities include a 250-bed psychiatric hospital at
Bingerville, a blood bank at Abidjan, and a pathological laboratory at
Treichville. The Pasteur Institute, slated for completion in late 1963, will
include a clinical biology laboratory and a laboratory for research in viruses
and rickettsiae. The project is financed by a CFA F260 million ($1 million)
grant by the European Common Market and supervised by the Pasteur Institute in
Paris, which will supply the six trained researchers to staff the Ivory Coast
institute.

     In 1962 all drugs and medical supplies had to be imported, but a project
was being considered for setting up local fabrication of vaccines by private
enterprise.

Personnel

     A lack of secondary school graduates and local training facilities has
caused a severe shortage in medical personnel and a heavy reliance on French
staff which will continue for some time. Although the French made a special
effort to train African doctors and pharmacists at the medical school in Dakar
between 1918 and 1952, most Africans who attended the school did so because it
was the only means to a higher education and not because they wanted to enter
the medical profession. Upon graduation, they preferred to enter politics or
commerce in a large urban center than to practice medicine in the hinterland.
Even today, African physicians are attracted by the lucrative practice and
high standard of living available in the cities, and French physicians on loan
from the French Government serve the remote areas in the hinterland.

     In 1961 the government medical service had 1 physician for 25,000
inhabitants, 1 pharmacist for 320,000 inhabitants, 1 dentist for 640,000
inhabitants, 1 midwife for 38,000 inhabitants, 1 nurse for 2,500 inhabitants.
Approximately half of the 128 physicians and probably more than half of the 10
pharmacists were French. The 85 midwives and 1,280 nurses were almost all
African, most of them men.

     Approximately 30 physicians, 30 pharmacists, 7 midwives and 280 nurses,
most of them French, were in private practice.

     At the end of 1962 the Ivory Coast had no medical school, but courses in
the first year of medicine were being offered by the Center of Higher
Education in Abidjan, and a medical school was planned for the near future.
Until 1952, Ivory Coasters could prepare to be doctors and pharmacists either
at the School of African Medicine at Dakar, where a 4-year course led to a
local qualification or at a medical school in France where they could obtain
full qualifications as state certified physicians or pharmacists. Since the
closing of the School of African Medicine, all Ivory Coasters have gone to
France for their medical training after initial preparation at the Center of
Higher Education in Abidjan or the University of Dakar.

     All physicians and pharmacists belong to the National Order of Physicians
and Pharmacists which regulates standards of practice and professional
conduct.

     Nurses and midwives are trained at the nursing school attached to the
Treichville hospital or in France. Auxiliary medical personnel are trained
in-service at hospitals, laboratories and research institutes. A few go to
France for special training.

     Medical personnel at all levels attached to mobile units fighting endemic
diseases receive special training at the OCCGE-operated Ecole Jamot at Dobo
Dioulasso in Upper Volta.

     All professional medical personnel-physicians, pharmacists, midwives and
nurses-must be certified by the state. French certification is automatically
recognized as valid.

Welfare

     In traditional Ivory Coast society, welfare assistance is given in the
context of the extended family or lineage. An individual is expected to turn
to members of his family for financial aid and guidance, and the family in
turn is expected to provide for the welfare of every member. In the village it
is easy for this mutual assistance to operate, but in the cities it becomes
inoperative because members of the family are not present. The urban worker
has, therefore, developed a substitute in the form of religious or ethnic
societies or simply savings clubs. The aim of these societies and clubs is to
provide a sense of security and belonging in an impersonal urban setting.
Members receive support from the society when out of work or ill, or they may
receive help for the rituals involved with the cycle of life. The societies
also provide social and educational functions designed to acclimate newcomers
to modern urban life (see ch. 6, Social Structure).

     Juvenile delinquency is becoming a problem in Abidjan and some of the
other large urban areas where young people are attracted to look for work and
excitement. The principal offense is petty thievery because the youths often
have difficulty finding suitable work and often lack parental supervision and
support. The government operates a re-education center at Dabou for the
rehabilitation of delinquent and maladjusted youth.

Private Welfare Activities

     Little is known about private welfare in the Ivory Coast. Besides the
mutual assistance societies, religious organizations operate schools,
infirmaries, nurseries for children of working mothers, and recreational
facilities for young and old alike. The Boy Scouts, Girl Scouts, and several
other youth organizations, such as young farmers' and young workers' groups,
are separated into Catholic, Protestant, and lay groups. All of them are
members of the Federation of Youth Movements and Associations in the Ivory
Coast (Federation des Mouvements et Associations de la Jeunesse de la Cote
d'Ivoire) and receive financial support from the Ministry of Education.

Government Welfare Activities

     The Ministry of Labor and Social Affairs is responsible for welfare
activities provided by the government. It administers the several social
security schemes; operates a number of social centers, orphanages and
nurseries; and has a staff of trained social workers who occupy themselves
largely with problems of urbanization. Social workers are trained at a special
school created in 1960 which offers two 3-year programs leading to
certification as either an assistant case worker or a fully qualified case
worker.

     The government has stated its intention to promote and popularize mutual
assistance programs among the people themselves rather than to engage in
government-operated social security beyond a bare minimum.

     Social security legislation in effect in 1962 included provisions for
workmen's compensation in case of death or injury, a retirement fund for wage
earners, and payment of family allowances to wage-earning families. The
retirement fund is operated on a voluntary basis, but the other two schemes
are compulsory for all wage earners. Copied almost entirely from the French
legislation on the same subject, the social security system provides
comprehensive coverage for the permanent wage earner. But wage earners
comprise only 6 percent of the Ivory Coast population, and even among these,
few are sufficiently. informed about their rights and privileges to take
advantage of the protection available.

     Workmen's compensation covers both injuries at work and occupational
diseases, and benefits include full medical care, including functional
rehabilitation, vocational training and payment of daily benefits during
temporary disability. The worker is insured by one of a dozen approved private
insurance companies which carry the risk, but the government directs the
operation of the system and sets the benefit rates and qualifications for
eligibility.

     The pension scheme was established in 1960. It is voluntarily subscribed
to by a majority of nonagricultural employers, including the government
itself, and is operated by the Retirement Fund (Caisse de Retraites).

     The payment of family allowances was introduced in 1956 and is based on
the French system. Its principal aim is to equalize the income and thus the
standard of living of the married worker with children with that of the single
worker. Allowances are granted monthly for each child whose birth has been
registered or confirmed by special court order. In 1959 the allowance was CFA
F650 ($2.60) per month per child. Since few births in the Ivory Coast are
registered, the number of eligible children until recently was very small.
However, workers are becoming increasingly aware of the system and its
advantages and have begun to register their children to make them eligible.
Special allowances are paid to expectant mothers during their term of
pregnancy, and a lump-sum grant over and above the regular allowance is made
at birth for the first three children. The lump-sum grant for the first three
children by any wife has placed a premium on polygamous marriage by assuring a
higher income for a man with a few children by several wives than that
received by a man with many children by one wife. In fact, the family
allowance system has not been very successful in accomplishing its
aim - raising the standard of living of the wage earner with a large family.
Grants are more often spent for conspicuous consumption and the acquisition of
additional wives than for providing food and shelter for the children. The
system is administered by the Compensation Fund for Family Allowances (Caisse
de Compensations des Prestations Familiales).

     All three social security schemes are financed through a fixed assessment
on the total payroll of the member employer and are heavily subsidized by the
government. The worker himself does not contribute.