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Thursday, 24th April 2014

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Who will have killed Ama Sumani?

When flight BA081 left Heathrow at 14.35 GMT on 9th January, one of its passengers knew that she was being taken not only to Ghana, but to almost certain death.

There is no doubt that she had broken the rules and overstayed her visa. Her legal representative conceded that the decision to remove her from the UK was fair, and merely pleaded for her on compassionate grounds. At eight o'clock that morning she was calm, although tearful, as the immigration officers approached her at the University Hospital in Cardiff where she had been receiving her dialysis.

A BBC video report on Ama Sumani in Accra following her arrival, engaged in fruitless attempts to persuade hospitals to provide her with further treatment, also shows her as being calm, without anger, bitterness or self-pity. Perhaps this is because she has become used to disappointments. After the death of her husband in 2005, she fell ill with malignant myeloma in January 2006. As a foreigner without legal status in the UK, she was not entitled to the operation, a bone marrow transplant, which would ordinarily be given to treat her cancer. In order to prevent 'health tourism' by desperately ill people from Third World countries, the British government had issued an edict in 2003 to restrict National Health Service provision of treatment to ineligible people. But at least, Ms Sumani was given dialysis in order to prolong her life.

Ama Sumani's illness is treatable. If she dies during the next few weeks or months, as is now very likely, it will be because human beings have taken decisions which result in her not getting the treatment she needs. Who then will be responsible for her death?

UK officials have acted with the due appearance of correctness. According to AFP: 

Britain's Border and Immigration Agency said it carried out removals "with courtesy and dignity".

"Part of our consideration when a person is removed is their fitness to travel and whether the necessary medical treatment is available in the country to which we are returning," a spokesman said.

And indeed, the necessary treatment is available in Ghana- to the few who have enough money. The BBC reported that:

A spokesman for Ghana's high commission in London said the country had two fully-equipped hospitals in Accra and further north in Kumasi.

He did concede that access to treatment was costly but said that if Ms Sumani was a member of the Ghana national health insurance scheme she would still receive treatment.

Unfortunately, the latter statement is not even theoretically true. It is possible that the spokesman at the high commission had not been briefed on the list of exclusions which apply to Ghana's national health insurance scheme (NHIS). This is the list:  

Excluded are the healthcare services that fall under any of these groups:

(a) Rehabilitation other than physiotherapy
(b) Appliances and prostheses including optical aid, hearing aids, orthopaedic aids, dentures
(c) Cosmetic surgeries and aesthetic treatment
(d) HIV retroviral drugs
(e) Assisted reproduction e.g. artificial insemination and gynaecological hormone replacement therapy
(f) Echocardiography
(g) Photography
(h) Angiography
(i) Orthoptics
(j) Dialysis for chronic renal failure
(k) Heart and brain surgery other than those resulting from accidents
(l) Cancer treatment other than cervical and breast cancer
(m) Organ transplantation
(n) All drugs that are not listed on the NHIS drugs list
(o) Diagnosis and treatment abroad
(p) Medical examinations for purposes of visa applications, educational, institutional, driving license
(q) VIP ward (accommodation)
(r) Mortuary services

As a cancer sufferer requiring either a transplant or dialysis, Ama Sumani would be most explicitly barred from treatment, even if she were a member of Ghana's rather rudimentary national health insurance scheme.

Ghana's total national income per person is $520 (US dollars) annually; this is about one-sixth of Britain's annual per-capita spending on a single budget item, the National Health Service. To keep Ama Sumani alive for one year by means of dialysis would cost $24,000.

Depending on estimates, Ghana has between 9 and 13 doctors per 100,000 people. In comparison, the UK has 164 doctors per 100,000 people.

For the Republic of Ghana to be able to make adequate medical provision for all its citizens who suffer from severe and chronic conditions would require not only major changes within Ghana, but also a drastic change in either the structure of the global economy or in Ghana's relative position within the global economy.

Cash and carry

Yet there was a time when the health treatments which were available in Ghana were at least provided without regard to ability to pay. In 1957 the country became the first in sub-Saharan Africa to win its independence from the British Empire. Under the socialist leadership of President Kwame Nkrumah, Ghana set up a national health service which was fully financed from state revenues.

Although Nkrumah was overthrown by a CIA-backed coup d'etat in 1966, it was not until 1971 that the government began to introduce charges to patients for hospital procedures. At first the fees were small, but the principle was established. Facing economic problems which included declining world prices for its main exports, cocoa and gold, Ghana acceded to demands from the IMF and World Bank for market reforms; these included, in 1983 and again in 1985, substantial increases in health service fees. Control of health services was also decentralised. Since 1992, hospitals have been required to raise funds by charging patients for the full cost of medication.

The implementation of these reforms, which were given the title of 'cash and carry', was accompanied by the claim that they would improve access to healthcare, due to the increased revenue from charges and better efficiency. The actual effects were described in a 1997 New Internationalist article by Daniel Mensah Brande: 

The cash-and-carry system is a product of the structural adjustment programme which the IMF and the World Bank have prescribed and which Ghana has been ready to adopt. It involves the wholesale withdrawal of government subsidies on health delivery. And since its introduction, cash and carry appears to have carried away health services from the people.

'The system is stinking and dehumanizing,' says a medical practitioner in one of the state hospitals. `Patients who do not have the ability to pay for medical services are turned away from hospitals only to die at home. The poor, the disabled and accident victims are being asked to pay on the spot before getting medical attention. This system has no human face. Our health service is in confusion.'

A pharmacist told me that that many Ghanaians come to him rather than a doctor when they fall ill. `They come here to avoid paying consultation fees: many of them do not have the money to buy even painkillers like paracetamol. The situation is very critical. I have on many occasions given out drugs free of charge.'

The Korle-Bu Teaching Hospital in Accra, one of the biggest health institutions on the African continent, has been reduced to a showpiece of human neglect and administrative lapses. It has become a breeding-ground for mosquitoes while mice and rats are rife in the wards. A visitor to Korle-Bu recently said: 'This place is no longer a life-saving environment but a death trap. You will certainly contract a disease if you come here.'

By 2004, the failure of 'cash and carry' to improve the availability of health treatment was evident not just anecdotally but through academic research.    Under international pressure, the IMF and the World Bank had dropped their insistence that Third World health services should charge user fees. The Ghanaian government therefore felt able to establish its current national health insurance scheme, which does substantially reduce the cost of treatment (except for excluded conditions) for those who are members.

However, it costs an annual $8 to join the scheme- a prohibitive amount to the many Ghanaians who earn little more than a subsistence income. Further, the benefits do not apply for the first six months of membership, during which members must pay both their NHIS subscription and the 'cash and carry' fees for any health treatments which they need. By 2007, 60% of people in Ghana had either not yet joined or had dropped out of the scheme.

Foreign aid

In return for following Western policy prescriptions, Ghana does of course receive money in the form of aid. Through the Department for International Development, the UK provided £78 million to Ghana in 2006; in 2007, British government aid included £7.5 million for the health sector.    But this is negligible when compared to the huge flow of medical resources from Ghana and other African nations to richer countries, particularly the USA, Britain and Canada. Thousands of doctors and nurses from the Third World, after being educated and trained in their home country, migrate to work in the British health service.  According to a 2005 BBC report, 60% of the nurses trained in Ghana have left the country, and three-quarters of young doctors leave Ghana within three years of qualifying. The report noted that:

If the doctors and nurses from Sub-Saharan Africa registered to work here over the last five years had actually been trained in the UK it would have cost £1.95 billion - almost four times as much as we've given in aid.

But those are statistics. The fact that average lifespan in Ghana is 60, as against 82 in the UK, is also a statistic. The names and faces of the hundreds of thousands in Ghana, the rest of Africa and many other Third World countries who are dying because they cannot afford adequate healthcare, are unknown to people in Britain.  Ama Sumani, on the other hand, spent several years in the UK. She has some friends here; and the BBC, several newspapers, a few members of Parliament and some church officials have taken up her case. Therefore there remains the small possibility that somebody will take a decision which will allow her to live.

Otherwise, she will die. Like the others, who also have names and faces, to those who know them.