Professor Olayinka Abosede, is the Head of Department of Community Health & Primary Care, College of Medicine, University of Lagos. In this interview, she addresses the dangers of open defecation and some community health challenges.

TNE: When we talk of community health, what exactly does that mean?

Just the two words; something that concerns the health of communities and community members and all of us are community members. So anything that concerns the health of people is community health.

TNE: Would it be correct to say that it targets geographical areas because you just said all of us are community members or we talking in a broad sense?

A community can be the whole country or it can be a state or a local government. It can be a ward and it can just be some streets. So you have Residents’ Associations that are made up of streets or if it is in the case of rural areas, villages together form a ward and the ward is still a community.

TNE: Are there diseases or health challenges that are specific to communities or certain geographical area?

The smallest geopolitical unit in Nigeria is the ward in terms of health related issues. Many conditions and health problems are common to all communities, but then there might be some specific problems that are more common in an area than in another. For instance, if you’re talking about malaria, the whole of Nigeria is affected by malaria, but if you’re talking about something like twinning, there are certain areas of Nigeria that you have more twins or when you are talking of health challenges like Female Genital Mutilation, there are certain areas where it’s practiced and other areas it’s not being practiced at all. Even for HIV, if you look at the spread in Nigeria it is more common in some areas than in the others.

TNE: Looking at community health small geographical areas, does it impart on the health of the larger community, which is the nation?

There is a Yoruba adage which says if a person is eating a grub, (which causes irritation of the throat), and you don’t warn him, when he eats it and he has throat problems, the noise from the throat will not let anybody sleep. It’s the same with health, what affects a member of the family certainly, directly or indirectly affects the rest of the family. If it affects a family, it affects a community and in the end it’s a national problem. Once it is affecting somebody who is a member of the country it affects the rest of the country.

TNE: Nigeria ranks high among countries where open defecation is still a problem, can we say that’s a community health issue?

It is a community health challenge. When you do open defecation, let us say into water and this person has an infection, that’s how all the water borne diseases spread. So imagine in the rural area, where a river or stream is passing, the people use the downstream to wash, bathe and do other things, but they think the upper stream is clean and drink from that part; but the upper stream is coming from the downstream of another place and they might have used the water and defecated in it and washed their clothes in it. That means the upper stream passing through the neighbouring community is not as clean as they think, so water borne diseases and infections pass from community to community.

Even pipe borne water is not 100% safe. Some of the pipes are inside gutters and a little hole in the pipe and the water is contaminated. People defecate in polythene bags and throw on the street. If a person has worm infestation, the faeces will definitely be contaminated. Once cars move on it and it mixes with the soil or dust, the ova of the worm can get into exposed food item and we have in the market, garri, meat, everything exposed. So when you’re soaking the garri you don’t know that the ova of the worm are in the garri. The ova of a worm can last in the soil for a hundred years so when people do indiscriminate defecation they’re spreading a lot of diseases.

TNE: So what should be done?

It starts from the community; educating the community to know that it is wrong to defecate openly and then for communities to know what to do about such situations, which is why I always encourage a ‘do with approach and not do for’ approach to health matters especially in the rural communities. The reason is that if you do it for them they may not appreciate your efforts or the reasons behind your interventions. For instance, in a community where they do open defecation, you may build toilets for them and they refuse to use them, but if you, at the beginning involve them in finding out what is needed to tackle the problem and they identify and ask for public toilets, if the toilets are built, they will use them.

TNE: Most times when open defecation is mentioned what comes to mind is passing solid waste, does urinating in the open space also pose health challenges?

Urine is going to dry up but it still contains some germs. There are bacteria in urine and they mix with the soil. If a piece of biscuit drops and a child picks it and eats, he or she can get infected just like with faeces.

TNE: One health challenge that keeps resurfacing in the country is Lassa fever, which is said to be transmitted by rats. Would it be correct to term Lassa fever a community health challenge?

If you do not deal with cleanliness and refuse disposal in the community, there will always be rats; you will breed rats and the rats are the carriers of this Lassa fever. Some people don’t mind rats moving around the house, but they forget that as the rats are eating they are defecating, sometimes into the food they eat. So as long as we do not tackle refuse disposal, rats would breed and Lassa fever will continue to spread.

They usually say we should have two dustbins in our kitchens; one for biodegradable waste, that is those that can decay and then one for non biodegradables like polythene bags and plastic bottles. The ones that are biodegradable you can actually bury and they become manure for your plants and it is advisable to have a home garden. In some countries biodegradable wastes are even used for biogas which can be used can be used in the kitchen.

We must learn how to separate refuse from the point of collection. Most things are just mixed up in Nigeria and then we throw them into the waste disposal lorries.

TNE: Whose responsibility is it to educate of the people?

We have those in the community that devote themselves to community issues. In Lagos, for instance, there are the ward health committees; at least, I know that we had some in the past, looking into issues of health. Then community leaders; they can have Town Hall meetings and they can discuss issues that affect them. The media are also very key to educating the people whether through newspaper, radio or television. When we were educating people about HIV didn’t we come up and talk, even with Ebola we heard a lot about it until people knew, same thing with Lassa fever, there was a lot of information about it.

So at the community level, health workers should go and talk to people, talk to them in the clinics, at town hall meetings; get people that can speak, even the residents’ associations. It is the residents who know the problem and should come together, whether it is two streets or three streets that come together, to form a residents’ association. They should discuss such issues; they can even invite experts to come and teach them and talk about all these issues.

We have so many organizations; road transport workers organizations, market women, they can be educated; it is just a matter of organizing and getting to the people. Once you gather the people together you can educate them.

TNE: In all these, where does the government come in or doesn’t the government have a role to play?

The government is always playing a role, in fact, when you hear health messages, you hear it is a message from the primary health care board in association with maybe an international partner. Government, of course, in the health clinics gives health talks. We must also promote private public partnerships in the effort to educate the people on what healthy living is all about.

Government is already doing something but government cannot do everything which is why we say the private sector must join, the community must be willing also, not to wait for government to always do things for them, but to do with them. They should be carried along with whatever government is doing because then it becomes the people’s programme and that would make it sustainable.

TNE: If we don’t get our acts together and do something, like you have talked about refuse disposal from the homes and all that, what are the implications?

We are already seeing some of the implications; when the drainages are blocked with polythene what do you get, flooding and then people move through such flood. In fact, at Idi Araba area of Lagos State, there have been times when school children fell into gutters and died. So if we do not do the right thing, we would always go from bad to worse because we are creating the problems ourselves instead of solving them.

You see when it rains; people sweep their houses and throw the dirt into the water that is flowing on the street to be carried into the drainage. Of course, you can have epidemics because the waters carry different bacteria; this is how cholera, typhoid and the likes spreads because they are water borne and if they are coming from an area you have pit latrines, not properly kept or too close to the wells that are dug, they would be infected. So we create the problems ourselves.

We must learn how to dispose of human waste. Thank God that it isn’t like before that they’ll just throw them over into the ocean, but we still have people who don’t use toilets and just do it in the open.

People allow their suck away be full to the point of seeping out. Not only is that an eyesore, it certainly can spread diseases.

TNE: You have talked about typhoid and cholera as some of the health challenges that result from some of our (un)hygienic behaviours, are there others?

In fact, I should mention air pollution. I saw a generator that a man put by his window ledge, he is at the first floor, so, of course, the fumes would go to those that are neighbours within the same compound. He is enjoying the cool air, but the fume from the generator is polluting the air people are supposed to be breathing and these things are irritants and they are also carcinogenic. The most dangerous aspect is that the gas most harmful in that fume, the carbon monoxide, has no colour and has no smell so you won’t even know when inhaling it. Families have died from closing the door and having the generator on.

Generally, air and noise pollution also give rise to health challenges. The noise emanating from the person selling videos with loud music blasting into the air and the noise from generators, of course, mean that people can’t sleep well. Therefore, we have more people getting irritable; if you don’t sleep well you get very irritable and your actions to other people cannot be as cordial as you want it to be, that is another problem.

TNE: What makes a community healthy?

A healthy life style will give a health community. A healthy life style means you are eating the proper foods, you are resting at the right time; exercising, which is very important, you’re not drinking alcohol excessively, nobody is smoking because when somebody is smoking and blowing the fumes into the air all the others that are sitting there are also smoking though passively. Then, are we keeping the community clean? Are we removing all the stored waters where mosquitoes can breed? Are we eating the right food starting from the pregnant women? Are babies fed according to the instruction of nutritionists and health workers?

Healthy lifestyle means you are taking care of the environment, you are taking care of personal hygiene- good hygiene and you are doing things that would promote good health. If the community would do all those things, the community would be healthy.

TNE: Given the economic challenges people are facing, is what you have said realistic?

It is very realistic and it is working in other countries. Some countries are healthier than others. Most people want to go and live in countries where roads are clean, no refuse on the road, you don’t see human beings urinating and defecating all over the place. If you live in such a place, you would be healthy because even the air you’re breathing is healthy. Also, healthy nutrition doesn’t have to cost so much. All that I have mentioned are not things that need a lot of money. You have cheap foods that give the proper nutrients and they are being wasted in our markets because our storage and distribution systems are still not good enough. If we would store and distribute appropriately, fruits would be cheaper, vegetables too. If you look at the food pyramid, carbohydrates are the most you should have and we have a variety of them. When we are teaching about nutrition, we say eat the locally available, cheap foods, not necessarily imported ones. Fresh foods are always better than all these processed ones. You can even have your own vegetable garden.

But many people are too lazy even to try. Everything is not money; there are a lot of things we can do without spending anything if we address the issues properly. But, of course, if you want to buy equipment for say health facilities you need money to do that, no doubt, but there are so many things we can do at the family level without spending. We always concentrate so much on the economy, it is not every food that is expensive, you can still get protein from beans, beans are not as expensive as eggs or if you cannot buy beef or chicken, you can at least buy Egusi or buy beans, they are also sources of protein. Egusi gives protein and oil, there’s fat in it too. There are some combinations that give you more nutrients like if you’re taking pap which is corn and beans and the beans can be just cooked beans or moi moi or akara. When you combine the two, instead of two plus two equals four for the amino acids you’re getting, you get more than four because some of those amino acids are formed by combining those in the corn and those in the beans and they are released and it is a balanced diet. This is not so expensive but it gives you proper nutrition.

TNE: How effective in your opinion is the primary health care in country?

When you say how effective, I cannot put a percentage, but obviously we can do better. Our primary health care system is still not at a level that is acceptable, infant mortality rate is still very high, maternal mortality rate is still very high, they are reducing but they are still too high for any person to accept because our primary health system is not as strong and sustainable as it should be. We seem to go one step forward and more steps backwards and then the population is increasing at such a rate that the services are not adequate enough for everyone, so when you’re talking about acceptable health care you’re talking about each person having access to basic quality health care which is not happening yet. Even the health facilities are not equally distributed, we have so many of them in urban areas and the rural areas are lacking, even in Lagos state you will find out there is a hub around Ikega axis where all the private and government facilities are located, but go to the extremes like Epe and Badagry, you’ll find fewer of those health facilities. And that, of course, impacts on the communities health.