Rural dwellers and health care in Northern Nigeria

5,~ S<I Mud Vol 15A. pp. 265 to 271. 1981 0271-7123 X1 030265.07SO2Wfb Printed m Greal Brttaln Prrpamon Prw Ltd

RURAL DWELLERS AND HEALTH CARE IN NORTHERN NIGERIA

MARGARET MURPHY and TUKUR MUH~MAR BABA

apartment of Sociology, University of Sokoto, Nigeria and Department of Social Science, University College, Dublin

Abstract-Villages and the health services available to rural dwellers in a northern region of Nigeria are described. The villages were visited as part of a social study of gynaecological patients attending A.B.U. Teaching Hospital. Zaria, to determine the availability and utilization of health care facilities. It was found that the majority of villagers had no ready access to orthodox health care facilities and. where such services existed, villagers used both orthodox and traditional systems. In the case of obstetric services, socio-cultural traditions and lack of education appear to affect adversely women’s propensity to utilise obstetric care. It is demonstrated that an efficient obstetric service can gain people’s trust so that they come to hospital more readily and so avoid complications in childbirth. The general picture presented, however. is one of deprivation. There is a lack of health services and those that exist are undermanned and ill equipped. Locally initiated cooperative enterprise indicates that an integrated approach to health care delivery would achieve good results in making health care facilities more readily available to the people. It was seen that it will be necessary to ensure a pure water supply. a good road system. educational and economic development, as well as more comprehensive health care coverage. if the general health status of rural dwellers in this region is to be raised.

INTRODUCTION

In the past decade the problems of rural health care delivery in the Third World have received much more attention than heretofore. The WHO has led a vigorous promotion exercise of primary health care programmes and there has been an upsurge of publications on the organ~ation of rural health care [1-7-J. The authors do not intend merely to add another account of the well known problems associated with rural health care delivery. Instead, they give an over- all picture of the socio-environmental context within which the organization of health services takes place at a local level with special reference to obstetric care. A descriptive account of this nature is of interest to health planners since it illustrates vividly the com- plexity of the social factors to be borne in mind when developing rural health care services. Janzen [8] points out the danger of a preoccupation with local problems is that it can result in a failure to recognise the wider socio-economic and political setting. None the less, to be effective, health care ~pl~entation requires knowledge of the particular problems to be faced at the local level and to take account of the life experiences of people seeking help [9].

MATERIALS AND METHODS

The villages described in this article were studied to determine the availability and utilization of health services by rural dwellers in a northern region of Nigeria. The information about the villages was obtained during visits to the home villages of patients and formed part of a medical social study of women suffering from vesico-vaginal fistulae (VVF) [lo]. The study was conducted in A.B.U. Teaching Hospital, Zaria by Professor U. G. Lister, Department of Ob- stetrics and Gynaecology, and Margaret Murphy, Department of Sociology, Ahmadu Bello University,

between 1976 and 1978. The village visits were made between January and April, 1978.

The patients to be visited were selected from 100 new attenders interviewed at the Gynaecology Clinic. For practical reasons those visited lived within 250 kilometres of Zaria and their villages were known to be on, or near, a motorable road. Patients with VVF come from a wide catchment area and 42 of the 100 new attenders lived further than 250 km from Zaria. Of the 58 remaining patients, 27 were eliminated. either because of an insufficient address or because their village was inaccessible. Ten of the remaining 31 patients were randomly selected to be visited. During each visit it was the intention of the research team [ll] to interview the patient, family members, and the head of the village or district. Poor communications made it impossible to visit by appointment and some visits were incomplete due to unavailability of one or other of the people to be visited. Six households of the initial sample were traced but only 2 patients, as 2 had remarried and were living elsewhere and 2 had been sent to live with other relatives. It was therefore decided to visit 2 long term VVF patients. one was escorted home and the other was to have been collected for a return visit to hospital but remained untraced. So in all 12 visits were made. 3 patients were located and interviewed as well as relatives in 7 of the households, 8 village or district heads. and on 9 of the visits other community leaders (e.g. school teachers) were also interviewed.

Visits were made to 9 villages, to 2 small towns and to a district of a large city when, in addition to learn- ing about their health care facilities, the research team gained information about their geographical and demographical features, economy and amenities. Sup- plemental data on obstetric rural health care was obtained from cassette recorded conversations with 40 patients receiving treatment in hospital.

265

266 MARGARET MURPHY and TUKUR MUHAMMAD BABA

Fig. 1. Location of 100 new patients interviewed 1976-1978.

PHYSICAL FEATURES OF THE VILLAGES

Villages in the Zaria region are attractively laid out, the more prosperous with compound wails of red mud and tree lined roadways. The villages are made up of clusters of family compounds, a group of mud houses with roofs of mud or thatch, and the oc- casional zinc roof, enclosed by walls of mud or guinea corn stalks. The schools are situated on the outskirts of larger villages and, in districts where the Funtua Agricultural Development Project (FADP) [12] is in operation, its buildings are found near the school buildings. All but one of the villages visited had market places. Compounds belonging to Village Heads [I31 have imposing mud walls and decorated door- ways but the compound where the patient lived was usually in a hamlet near the principal village. The hamlets are much poorer than the larger viffages, with guinea corn stalk walls and thatched roofs. Even the outer wall surrounding the hamlet is made of guinea corn stalks, not always well maintained [14].

The landscape is typical of the savanna region, open land with bush and trees adding colour even

before the rains. The villages are approached by Iater- ite roads and are characteristically built on a rise of land with a river in the valley below.

WE RURAL DWELLERS AND

THElR ECONOMY

The popuIation size of the villages varied between about 800 and 2SOO. A village where accurate demo- graphic records were kept for the district had a population of 4510, over 40% of whom were children and less than Zoo/, were classified as eideriy. The main occupation of the men is farming with cultivation of both subsistence and cash crops, guinea corn, ground- nuts, millet and in some districts, vegetables, cotton and sugar cane are also grown. Sheep, goats and fowl are kept in the villages. Sometimes rural Hausa women become highIy suecessfui traders but it is more usuai to find the women undertaking the typical Hausa-Fulani subsidiary jobs in the home, such as spinning thread, preparing groundnut oil, ~oundnut cakes and other foodstuffs for seiling. Farming activities vary with the season, there is 6 months rainy

0 Prhdpal rawns

Fig. 2. Location ol villages visited.

Health care in Northern Nigeria 267

I N= 151

0 Zarib 200 300 4t1O 660 6OO+

Kilometres from Zone

Fig. 3. Distances patients live from Zaria: patients who had VVF repair operations in 1972.

season, 6 months dry season. during which the Har- mattan [ 151 can be severe. Seasonal migration of young people is the norm. There are many Fulani settlements. semi-nomadic cattle herdsmen and their families. The research team visited a settlement in a hamlet about 3 km from the nearest village. When the rains come the men move off with the cattle to seek new pastures, but the womenfolk frequently remain behind. Such settlements can be well endowed with cattle and poultry but malnutrition among the children is common as it is contrary to local custom to give meat or eggs to children.

Eight of the villages hold weekly markets. On market day transport comes to the village, mainly lorries carrying goods to and fro; 4 of the villages are served by public transport. The village heads own motor cycles and some villagers have bicycles, but the majority face a long walk before reaching public transport. Five of the villages are aided by the FADP. The programmes can have important implications for the health of the community in the long term, since they offer the chance of improved production, better roads, and a pure water supply. Two of the villages have electricity and so are able to enjoy TV, even the most remote hamlet has its transistor radio. The main entertainment and exchange of information are pro- vided by family occasions. such as naming ceremon- ies, on market day and at religious gatherings. The Islamic faith predominates and, for the most part, women are enclosed. In the villages men of all ages

I N = 215

0 Zaria 50 100 2003OO4006OO6OO+

Kllometns from Zone

Fig. 4. Distances patients live from Zaria: patients who had VVF repair operations in 1977.

were standing around, as there were few farming activities. and young girls, most of whom were not attending school. The inception of universal primary education in Nigeria means that larger villages have their own schools, but, in the villages visited, these are mainly attended by boys. The girls are to be seen hawking foodstuffs and other goods prepared by the women who are confined to their compounds. Adult education for women is not fully accepted; 3 of the villages had classes in home economics for women whereas in 6 adult literacy classes were held for men only.

Some villages are tidily kept, the refuse is disposed of by collecting it from the compounds, burning it, and taking the ashes to the farms as fertilizer, and the roadways are clean. In others the villagers seem to have lost heart, feeling that they have been forgotten by “the Authorities”. On one occasion it was observed that a low lying well was in steady use, although there were two other wells nearby. This well was uncovered and some of the water spilled back into the well as people walked around in the muddy water at its edge. The research team were the first representatives of orthodox medicine ever to have visited the village but it was disappointing that the agricultural development officers had not made sure that the villagers ceased to risk their health by continuing to use a contaminated water supply.

HEALTH CARE SERVICES

The provision of health care services in the villages was negligible. The two towns visited had small hospitals and 4 of the villages had dispensaries. The roads to 3 of the villages become impassable during the rainy season and, even in the dry season, the roads to many of the villages are deeply rutted and would give a sick person a rough ride to hospital. Of the 5 villages without a dispensary, 2 were situated 6 km and 10 km from the nearest dispensary and 3 were nearer a hospital than a dispensary, the hospitals being 14 km, 22 km and 27 km from the villages, but only one of these villages, the one nearest a dispensary, had public transport.

A community based hospital

In one of the small hospitals visited, serving the town and surrounding villages, a total population of about 30,000, there was a shortage of basic equip ment. The medical staff consisted of an expatriate husband and wife team and a doctor serving his national youth service [16]. There was an acute shortage of qualified nursing staff. A doctor mentioned that while sophisticated medical hardware was lying unused, it was extremely difficult to obtain basic equipment, such as catheters. In his first week of duty this doctor had witnessed three maternal deaths through haemorrage. He said that local people regarded the hospital as a place to die. This became a self-fulfilling prophecy as patients delayed coming to hospital until it was too late to help them. TWO patients suffering from VVF had recently been admit- ted. Both had come to hospital after dehvering a stillborn baby at home; one, in addition to her fistula, had a drop foot and was partially crippled.


Village dispensaries physical. Patients often report that before coming to As the name implies, the services offered by the hospital they tried “rubutu”. A Mallam chalks prayers

dispensaries are principally to dispense medicines, but on to a slate, the writing is washed off into a beaker

valuable advice on health problems is sometimes and the liquid drunk as medicine. Some Mallams pre- given. Some have extended their services to include pare their own medicine and protective amulets. In a general medical clinics, antenatal clinics, vaccination Fulani encampment it was learnt that family members

services, and mother and baby clinics. The concept of trekked about 15 km across the bush to reach a vil- a health centre is still quite new in this part of the lage where a well-known Mallam had his own “dis- country. Despite references in the National Press to pensary”. If his remedies were not successful they their desirability, the reality of health centre buildings, would then go to the health dispensary in the same staff and equipment is still unknown to many rural village. In general, however, they found the treatment dwellers. In one village it is planned to open a health received from the Mallam cured their complaints. centre with 12 beds and to extend the range of ser- On one visit the research team’s guide was the local vices offered as part of a State scheme to establish bone setter. He spoke proudly of this inherited skills primary health care services on the lines advocated by but said that he referred people to hospital if, in ad- the WHO [17]. At the time of the visit this village dition to a broken bone, the skin was broken as he had a dispensary opening daily, with nursing and did not know how to prevent infection. Bone setters auxiliary staff and close liaison with the local hospital enjoy wide recognition in society and are considered situated 20 km away. The village head, a well-edu- more skilled than their hospital counterparts. Hospi- cated man himself, encouraged all the children to tal staff, on the other hand, deplore their methods attend school and pressed eagerly for modern facili- which can leave people permanently deformed or lead ties in the village which had electricity and communal to gangrene and amputation of limbs. TV, and was situated in a prosperous farming area. Since the research team’s interest was centered on Dispensary buildings are small and it was said that the availability of obstetric care and the associated their stocks of medicine frequently ran out. This is problem of VVF, the only detailed knowledge of sur- hardly surprising when esssential drugs are often lack- gical practice is that of gishiri cutting. This may not ing in hospitals. Both of the hospitals visited suffered be administered by a barber surgeon as such, but by from staff shortages and lack of equipment; it will be an elderly woman recognized to be proficient in this an even more difficult task to find trained staff to man skill. Gishiri is the Hausa word for salt but, in the village clinics. context of illness, refers to diseases of the vagina.

When health services are lacking, where do rural Murray Last (1976) describes it as “the omnibus com- dwellers seek help if they become ill? Drug hawkers plaint for women of childbearing age irrespective of are becoming increasingly popular as healers and are whether they are or ever have been pregnant” [ 181. It frequently consulted about all sorts of complications, is treated by incision into the anterior wall of the sometimes with fatal results. Little check is made on vaginal orifice. If the cut is made too deep, it can be a their activities and stalls where they sell their wares direct cause of vaginal fistulae. Darrah and Froude are to be found in the village markets. Villagers hear Cl93 estimated that in the Zaria region about loO/, of about certain drugs and remedies through radio ad- the fistulae treated in hospital are directly caused by a vertisements: such drugs are described as a panacea gishiri cut and a further 30% by a combination of for all ills and are sold indiscriminately by the obstructed labour and gishiri cutting. The razor or hawkers, who are more often than not illiterate them- sharp instrument used to make the incision is not selves. Time and again the research team was given to sterilized which adds to the dangers of this practice. understand that the people wished to receive modern Murray Last found that “Older women have never health care. In those villages with a dispensary or had gishiri cutting done to them, but they often make near a hospital, it was asserted that traditional medi- young women giving birth for the first or second time cine was on the wane. The evidence is that traditional have it done” [20]. Patients consider a gishiri cut to practitioners continue to thrive, even when health ser- be particularly helpful in relieving obstructed labour. vices are readily available. Possible reasons for this in the treatment of prolapses and for infertility. are that some ailments are believed to be more effec- Patients who are successfully repaired by surgical tively treated by traditional methods, traditional operation for a fistula caused by a gishiri cutting have medicine is more accessible. and its practitioners been known to return to hospital with another fistula more familiar to the people. after a further gishiri cut. That such potentially harm-

ful practices continue to exist is partly due to the inaccessibility and inadequacy of the health services.

THE TRADITIONAL SYSTEM OF Other factors will now be considered, such as the

HEALTH CARE influence of socio-cultural beliefs and education on the utilization of obstetrics services. It will be demon-

In Northern Nigeria there are a variety of traditional healers but, during the visits, those most fre-

strated that an efficient health service can gain

quently mentioned were Mallams, herbalists, bone people’s trust so that they come for treatment earlier

setters, barber surgeons and traditional midwives. and hence complications caused by difficult childbirth

Koranic medicine practised by Mallams is highly can be prevented from occurring.

regarded. Mallams are local people versed in religious Socio-cultural factors knowledge and theology who, as a part time or full time activity, invoke spiritual powers in healing a

In Hausaland it is customary for women to be mar-

whole range of complaints. both ohvsical and non ried before menstruation commences and among the ^^

I , 100 new patients interviewed in the research study. a


conservative figure of 50 were pregnant before they reached the age of 16. Early marriage is supported on social grounds. to prevent premarital pregnancy and promiscuity. Harrison comments that “whatever social benefits early marriage may have, it is associated with high maternal and perinatal mortality, largely because in many of these girls childbirth may be difficult even with comparatively small babies” [Zl]. Because of the risks involved, it is especially important for young mothers to receive expert care before and during delivery, but it is customary in Hausa society for a mother expecting her first baby. and frequently her second, to be confined in her parents’ compound. Moreover, “kunya”, where a young bride assumes a modest, reserved role in the house- hold. means that when she becomes pregnant she is expected to keep quiet about this and the forthcoming birth is not discussed. Patients mention being in labour for days before action is taken. If complications are suspected, a gishiri cut may be administered. The patient’s mother usually stays with her during labour. After the baby is born it is the maternal grandmother who will bring up the first born child. Custom decrees that the mother pays little attention to her first child, to the extent that when attending hospital a Hausa woman may not mention her first born child, saying that it is her first pregnancy when it is in fact her second. The majority of patients who come to hospital with a fistula report that they were in labour at home for 3 or 4 days before seeking help, or had given birth at home with no outside help. It is obligatory for a wife to have permission from her husband to attend hospital. If he is away from home when she falls ill or is in labour, she will not be allowed to come to hospital until his return. If the couple are young the husband’s mother or some older relative decides what is to be done. The following extract from a case history illustrates the problems that may occur as a result of this:

She attended an antenatal clinic regularly until shortly before her confinement when she was sent to her husband’s parents’ house. She was stopped from attending the clinic and. when she went into labour was not allowed to go to hospital. She was in labour for 5 days before being brought to hospital. The hospital was in the very town where her parents-in-law had their compound. By this time it was too late to save the baby and the patient started to dribble urine shortly after giving birth to a stillborn baby.

Education and awareness of the illness situation

It is rare to meet a literate VVF patient. It was noted on the village visits how few young girls were attending school. Findings of the study on the patient with VVF showed that only 12% of the patients with VVF had even one relative who had received second- ary education and of the 33% who had relatives with primary education. the majority were younger brothers or nephews of the patient. Research findings elsewhere indicate that the more highly educated are the quickest to respond to illness situations and are less tolerant of illness symptoms [22]. Added to this are the practical problems involved which prevent rural populations from seeking prompt medical aid. The stoical nature of patients coming from the Hausa culture is undoubtedly another reason for delays in

seeking treatment. Any medical service wishing to reach people coming from this tradition must be alert to their stoicism and fatalism if they are going to meet their needs. This fatalism is adverted to by Mrs Odebiyi [23] when discussing the influence of Mos- lem beliefs on a patient’s utilization of health care facilities.

Lack of education in itself can deter people from attending hospital if they are made to feel stupid and when hospital staff come from an alien culture with different traditions, customs and language [24].

A growth of trust in the orthodox system

Figures 3 and 4 illustrate the changing pattern in the distances patients with VVF live from Zaria Hos- pital. The addresses of patients who received surgical repair operations in 1972 were compared with those who received surgical repairs in 1977. In 1972, 15 patients (10%) came from Zaria or its environs and a further 26 (17%) from less than 50 km from Zaria. By 1977 only 4 (2%) came from Zaria and a further 13 (6%) from less than 5Okm from Zaria. Of the 100 new patients interviewed in the research study, none came from Zaria and only 6 came from more than 20 km but less than 50 km from Zaria. This pattern has persisted. The numbers of patients have continued to increase but new patients are not from Zaria or its environs. It would appear that women living within reach of Zaria are coming to hospital as soon as labour becomes prolonged and hence their babies are delivered safely. Some patients with VVF are physi- cally unable to reach a hospital in time to save their baby but others fail to use the available hospital services. From the research findings, 42% of the patients lived less than 50 km from a hospital and 23% were known to live in villages with motorable roads to the nearest hospital. Only 9% mentioned inaccessibility as preventing them from coming to hospital and 8% said that they had no money for the fare. 33% were brought to hospital, but too late to be helped, and 27% simply never thought of it. Cultural traditions, lack of education, and lack of trust in the hospital system contribute to a failure to seek help. These findings should not cloud the severe practical difficulties some rural dwellers experience as the following two examples illustrate:

“What do you mean by antenatal care? We do not know such things in our village. If somebody is sick we just have to put them in a truck, the road is very bad so no buses come to our village, there is no hospital around, not even a dispensary. It is only if somebody is really ill and if our own remedies fail that we go to hospital.”

“I was in labour for 3 days at home. I was given some medicine by the Mallam and prayers were said but they didn’t help. I was put on a donkey and we trekked for 3 days before reaching a motorable road. At last I had my baby in hospital after 7 days’ labour and it was born dead.”

Co-operative enterprise

Practical difficulties can be overcome and some hopeful signs for the future were seen during two of the village visits where co-operative enterprise has already achieved impressive results. The first village used to be 14 km from a motorable road. The villagers formed their own development association,


choosing a local farmer as their leader. Through cooperative effort they built a motorable road, connect- ing their village to a main road and giving them access to amenities such as health services. People in the second village were clamouring for their own health clinic and complained bitterly of the broken promises made by politicians prior to the local elec- tions. Attention was drawn to the beautiful new Mosque they were able to erect through their own efforts and it was suggested that if they showed the same initiative with regard to building their own health clinic, the authorities might move more quickly to honour their commitments. With an appreciative regard for the enterprise already shown, these villages could prove fertile ground in which to develop rural health care programmes.

DISCUSSION

The observations made on the village visits con- form to the general comments made about ruraf. health care in the majority of Third World countries. The picture that is presented is one of deprivation. There is a lack of health services and those that exist are undermanned and ill-equipped. Basic amenities, such as electricity and public transport, are rare. Even in areas where the FADP has made a positive impact on agricultural practices, there is no evidence that community development techniques have been employed either to involve rural dwellers in decision- making or to incorporate health services into an integrated development programme. Of particular con- cern is the apparent lack of encouragement given to girls to attend school and the absence of adult literacy classes for women. Research findings reported by Kosa er al. [25] indicate that a mother’s lack of education is the most ~~rtant so&o-economic factor affecting perinatai mortality. Health education programmes relating to obstetric and child care practices could usefully be directed towards older women since it is clear that the senior women are the decision makers in matters relating to the everyday life of the compound. Greater use could be made of the radio to encourage hygiene in the home, especially if such advice was given during farming programmes which are said to be the most popular. That such co-operative community health programmes are feasible has been illustrated in other parts of Nigeria, notably in the field of psychiatry, by the Aro Community Experi- ment [26] and by the Igbo-Ora experiment in preventive psychiatry [27).

Traditional and orthodox medicine continue to exist side by side as is seen etsewhere in Nigeria c26.273 and in many other parts of the world [28.29]. The mutual suspicion with which practitioners of the two traditions view one another is not shared by their patients. Given a choice, they select whichever service is most convenient or believed to be the more appropriate. Attempts have been made to incorporate traditional midwives into the orthodox system of health care by introducing training programmes in two districts visited by the research team, yet the numbers of patients with VVF coming to Zaria Hospital from these areas continue to rise. Part- nership between traditional and orthodox medicine appears to be a practicable way of extending health

care, but this can only be effective if personnel in both systems are really convinced that they can work together. Asuni [30] has pointed out that it is dan- gerous to assume that the integration of the two systems is practicable or necessarily in the interests of improved health care.

Village leaders reported that the most common diseases were malaria, schistiomiasis, measles and diseases caused by malnutrition. These are all prevent- able conditions, as is VVF. It has been demonstrated that an efficient obstetric service can lessen the risk of such costly afflictions as VVF, costly both in terms of human suffering and in tha material costs of lengthy and highly specialized hospital treatment. VVF is sel- dom found in urban communities, it is largely a rural problem. Patients who develop VVF are usually small. This is partially because they are young but also because they are characteristically of low socio- economic status. coming from subsistence farming backgrounds. The prevention of this health problem will not be brought about by efficient obstetric services alone but the so&o-economic development of rural areas will resuh in the removal of such predis- posing factors as malnutrition, lack of education and poor communications. This is most likely to be achieved through an integrated approach to rural development such as that advocated for Nigeria by ‘Dupe Olatunbosun [30] and in the health field as a whole by the WHO and others [31,32]. The observations made on these village visits show that not only improved health services but a pure water supply, sanitation, a good road system, education and economic development have yet to play their part in raising the general health status of rural dwellers.

~ck~ow~e~~e~ents-we wish to thank Professor K. A. Harrison, -Department of Obstetrics and Gynaecology. A.B.U. Teaching Hosnitai. Zaria. for his constant encouragement and advice. both during the period of the field- work and in the preparation of this article and MS M. Batchelor, Acting Chief Medical Social Welfare Officer, A.B.U. Teaching Hospital, Zaria. for her generosity in releasing Mrs Oyesile from departmental duties to act as research assistant.

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Fabrega H. Jr. Dynamics of medical practice in a folk community, Milhank mend Fund Q. 48, 391. 1970. Vesico-vaginal fistula is the gynaecological term for an injury that generally occurs as the result of unrelieved obstructed labour in childbirth. The resultant prolonged pressure on the bladder can lead to an opening between the bladder and the vagina. The baby is stillborn and the woman is left childless. incontinent of urine and sometimes faeces as well. The research team consisted of T. M. Baba who interviewed the village leaders and male relatives of the patient, and Mrs Oyesile. a senior welfare assistant, A.B.U. Teaching Hospital, Zaria. who interviewed the patient and her female relatives. and Mrs Murphy who acted as observer and team leader. On two occasions Professor Lister was able to join the team. Funtua Agricultural Development Programme (FADP) was set up to improve standards of agriculture in the district around Funtua. Kaduna State. As well as introducing modern farming methods, motorable roads have been built and water supplies improved in the area. Village Heads are in charge of the general administra- tion of the villages and are responsible to District Heads who. in their turn are answerable to the Emir- ates in Northern Nigeria with regard to local affairs. For a more detailed description of Hausa compounds see Hill P. Rural Hausa: A Village and a Serring. Cam- bridge Univ. Press. 1972. The Harmattan period is when the region is under the influence of the cold, dry and dusty North East Trade Winds blowing across the Sahara Desert southwards. National Youth Service Corps refers to a year’s com- pulsory national service for all Nigerian graduates on completion of their final qualifying examinations. Graduates are posted to a different part of Nigeria from their home State with the purpose of encouraging greater understanding between the peoples of Nigeria and fostering a heightened sense of national identity. Newell K. W. Health by the People. WHO Publication, Geneva. 1975. Last M. The presentation of sickness in a community of non-Muslim Hausa. In Social Anrhropologr anh Medicine (Edited bv Loudon J. B.). on 131-136. Aca- demic Press, New- York. 1976. This describes the Hausa concept of gishiri as a disease. Darrah A. and Froude J. Hausa Medicine,for Western Docrors. Zaria 1975. Op. cir. Last M.. p. 131. Harrison K. A. Childbearing in Zaria. A Public Lec- ture in Ahmadu Bello University. Zaria on 20th March 1978.

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36.

See for example Koos Earl D. The He&h OJ Rrgion- oil/e. New York, 1954. Odebiyi A. I. The socio-cultural factors affecting health care delivery in Nigeria. J. rrop. Med. Hyg. 80, 249. 1977. Fabrega H. Jr. and Roberts R. E. Social-psychological correlates of physician use by economically disadvan- taged Negro urban residents..Med. Care Xi 215. 1972. Kosa J., Antonovskv A. and Zola 1. K. eds. Povrrr v and He&h: A Sociolog&l Analysis. Harvard University Press 1969. There have been many publications about this experiment initiated by Dr T. A. Lambo. but special reference to community involvement is made in Asuni T. Community and public health: by-products of social psychiatry. W. Afr. Med. J. 13. 151, 1964. Ayonrinde A. and Erinosho 0. A. A pilot experiment in preventive psychiatry in a rural community: the case of Igbo-Ora in Nigeria. Inr. J. Hlrh Educ. 20, 2. 1977. See for example Maclean C. M. U. Maaicnl Medicine:

A Nigerian dose Study. Allen Lane, 197<. Ademawagan Z. A. Problem and prospect of legitima- tising and integrating aspects of traditional health care systems and methods with modern medical therapy: the Igbo-Ora Experience. Nig. Med. J. 5, 182. 1975. See for example Shiloh A. The interaction between the middle Eastern and Western systems of medicine. Sot. Sci. Med. 2, 235. 1968. Camazine Scott M. Health care among the Zuni Indians of New Mexico. Sot. Sci. Med. 148. 73. 1980. Asuni T. The dilemma of traditional healing with special reference to Nigeria. Sot. Sci. Med. 138, 33. 1979. Olatunbosum ‘Dupe. Nigeria’s Neglecred Rural Major- ity. Oxford Univ. Press. Ibadan. 1975. An integrated approach to primary health care is advocated in WHO publications. such as Flahault D. An integrated and functional team for primary health care. WHO Chron. 30. 442, 1976. A practical example of an integrated approach is described by Idriss A. A., Kolik P., Khan R. A. and Benyoussef A. Health care facilities in developing countries. The primary health care programme in Sudan. WHO Chron. 30. September. 1976. Oyemade A. and Olugbile A. Assessment of helath needs of agricultural workers in Nigeria. Publ. HIrh 91, 183. 1977. They caution that any measure to improve health status must include health education, environmental improvement, better medical coverage, and active community participation in health care delivery at village level.

Rural dwellers and health care in Northern Nigeria

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