AFRO-NETS> Can non-profit organizations be hazardous to public health?

[A Odutola <chpss_abo@yahoo.com>]

Can non-profit organizations be hazardous to public health?
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[Apologies for the length of this analysis]
 
Yes, they can be. This is more so when they embark on camouflaged 
profit-oriented public health intervention programmes with little or 
no medical supervision and no regulatory oversight.
 
This viewpoint is illustrated with a typical case analysis.
 
The Executive Office of the First Lady was introduced into public 
governance in Nigeria at Federal and State levels back in the early 
80?s during the reign of General Babaginda as military dictator. The 
first ladies freely created ?do-good? non-profit organisations and 
used public and ?voluntary? donated funds to engage in diverse ?pub-
lic-spirited? programmes. Although the declared general objective was 
always to better the lives of Nigerians, the undeclared core motive 
is always political. 
 
Interestingly, a non-governmental organisation recently filed a case 
in Nigerian court praying the court to compel the first ladies to 
give proper and public account of funds raised by their respective 
non-profits from the public. 
 
Among the many programmes embarked on in the past by the first la-
dies, were various public health intervention projects like de-
worming children in selected schools, small communities or at state 
levels. Many of these public-health projects were conducted without 
clear public evidence of proper medical supervision and or regulatory 
oversight. 
 
None of the public health projects have been as audacious and ambi-
tious as the most recent one by the Child Care Trust in collaboration 
with a profit-driven commercial pharmaceutical enterprise, Emzor 
Pharmaceutical Industries Nigeria Limited (Emzor).
 
According to press advertorial by the project implementers (e.g. in 
The Guardian, Monday June 23, 2003 at page 62), the Child Care Trust 
in collaboration with Emzor, will embark on a national programme of 
de-worming Nigerian children using albendazole. 
 
The advertorial cleverly indicated that albendazole is a World Health 
Organization recommended drug. It also added for good measure that 
the First Lady, Mrs. Obasajo, approved the implementation of the na-
tional scale programme, as a ?gesture of her sterling love for Nige-
rian children?. As part of the programme launch activities on the 
27th June, 2003, ?a strong and powerful advocacy group for family 
health in Nigeria, made up of the wives of the Executive Governors of 
the thirty-six states and the Federal Capital of Nigeria, with the 
wives of prominent government functionaries will be tutored on child 
development and other relevant family care issues?.
 
What the advertorial did not tell the public is that albendazole 
though an effective de-worming agent must be used under strict medi-
cal supervision and may like many drugs also have unsalutory side ef-
fects. 
(See: http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202668.html) 
 
Just for proper orientation, the Child Care Trust was founded early 
in the year 2000 by Mrs. Stella Obasanjo, wife of President Obasanjo 
of Nigeria and the First Lady of the Federal Republic of Nigeria. 
Emzor Pharmaceutical Industries Limited is a profit-driven local pro-
ducer of basic pharmaceutical products like vitamins, anti-malarials, 
painkillers and of course the de-worming agent, albendazole. 
 
Emzor will supply the Child Care Trust project with albendazole at a 
?highly subsidized price? and ?spend a substantial percentage of 
profit on social development, particularly in support of the Child 
Care Trust?s Special Education Programme?. Mrs. Stella Okoli, (an-
other Stella!) founded Emzor. She is a member of the inner circle of 
Nigerian women achievers publicly associated with the First Lady, Mrs 
Stella Obasanjo.
 
To justify this national scale de-worming programme, the advertorial 
said that ?worm infection is a major world problem and more than one 
quarter of the world?s population suffer from intestinal worm infec-
tions. Nigeria, being no exception. The impact of worm infection on 
the health of our people is considerable and children are particu-
larly at risk. Worm infection is part of the problem of malnutrition. 
The two go hand in hand.?
 
This programme raises a number of national public health and ethical 
issues.
 
First, the public health issues: 
 
1. Apart from its do-good intentions, the programme?s advertorial 
owes it to the public to highlight the professional competence of the 
implementing partners to embark on such a large-scale public health 
intervention programme. 
 
In addition, the programme owes it to the public to supply answers to 
the following non-exhaustive questions:
 
2. What medical team or institution would be providing the mandatory 
medical supervision of the programme? 
 
3. Assuming that albendazole as manufactured by Emzor has been regis-
tered with Nigeria?s National Agency for Food, Drug Administration 
and Control (NAFDAC) and certified for use in the Federal Republic of 
Nigeria as a prescription only drug, who would be prescribing this 
drug for use by Nigerian children at the scale of the project and 
where are the safety data for the large scale use of Emzor?s albenda-
zole on children? 
 
4. What local baseline study informed the programme for such national 
scale engagement of de-worming children? 
 
5. How would the programme be evaluated for its medical impact and 
unforeseen consequences (if any)? 
 
6. How would the programme?s unforeseen consequences (if any) be man-
aged? 
 
7. How would the programme identify children suffering from diverse 
worm infestation or would it just administer albendazole to all chil-
dren irrespective of whether they suffer from worm infestation? 
 
8. Is there evidence that albendazole administered prophylactically 
protects non-infected children from worm infestation? 
 
9. Was the programme?s protocol submitted to any Ethics Review Board 
(National or Institutional)? 
 
10. Did an Ethics Board and/or the Federal Ministry of Health approve 
the programme?s protocol for implementation? 
 
11. How is the issue of informed consent and participant autonomy to 
be addressed by the project? 
 
12. What oversight role is the Federal Ministry of Health playing in 
such a national scale programme?
 
In view of the potential hazards inherent in public health interven-
tion programmes of the scale planned for execution by the Child Care 
Trust, the need for urgent answers to these questions cannot be over-
stated.
 
Now to key ethical issue: 
 
Without impugning on the integrity of the parties to this project, 
both may unwittingly be ensnarling themselves in ethical charges, to 
wit; insider dealing, racketeering and financial round tripping. For 
illustration, consider the following: 
 
13. The wife of a head of state, partners with a profit-driven local 
manufacturer of a drug to raise funds from the public. The funds so 
raised are used to procure a drug from the local manufacturer, albeit 
at a subsidized cost. The drug although administered free of cost to 
children will generate profit to the manufacturer. Profits realized 
by the local manufacturer from the sale of the drug are to be sub-
stantially funnelled back to the public trust of the wife of the head 
of state to support its activities. 
 
Can non-profit organizations be hazardous to public health? Make your 
own judgments, please.
 
In the interest of public health safety and just in case the partners 
to the national de-worming of Nigerian children have not thought 
through some or all the various concerns enumerated non-exhaustively 
above, they would be better advised to: 
a) Immediately suspend the implementation of the project; 
b) Engage specialist public health advisers, ethicists, communica-
tions specialists and programme managers to properly re-design a 
scaled back programme for implementation with convincing regards for 
public health safety and ethical concerns; 
c) Communicate convincingly with the public that proper public health 
safety measures have been put in place for the project; 
d) Divorce the project from its embedded ethical dilemmas. 
 
If the programme implementors fail to satisfactorily and publicly ad-
dress the concerns raised, then the Federal Ministry of Health owe a 
duty to the public to abort the programme immediately until these 
concerns are fully addressed.
 
Comments are welcome in the interest of the promotion of ethical and 
safe public health practice in Nigeria and elsewhere.
 
A. Odutola 
Centre for Health Policy & Strategic Studies (CHPSS)
Lagos, Nigeria
mailto:chpss_abo@yahoo.com
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