Civilized democracies and the wise words of Gandalf

Updated: Apr 21

by Dr Mark Nicholson

In February 1938, the Chicago-born British politician, Chips Channon, wrote in his unredacted and unbowdlerised diary: “I am always surprised when people here cannot understand the vigorous new civilization of the Nazis”. If you think the words ‘civilization’ and ‘civilized’ mean more or less the same thing, think again. They have the same root but surely mean something completely different. The Aztecs and the Incas were great civilizations but were hardly very civilized, but then nor were the Conquistadors. Many civilizations have treated human sacrifice, genocide and war as the norm.

On a personal level ‘civilized’ encompasses many attributes such as good manners, respect for others, tolerance, freedom from prejudice and discrimination, and philanthropy. A civilized country is one with a well- developed system of government, a fair justice system and which treats the people who live there fairly. Food and culture are surely secondary. Yet if someone were to ask me for the three most important qualities of a civilized society, I would say free quality education, free health care and the absence of the death penalty. The last two criteria immediately exclude the two wealthiest and most powerful countries in the world.

I will deal briefly with the latter first. It is well known that the death penalty is no deterrent, and that abolishing it has no effect on the murder rate. The murder rate in the USA is consistently more than five times the average for European countries. Moreover, apart from there being a chance of a wrongful conviction, an eye for an eye seldom works. I proffer no alternative for the ‘correct’ punishment for heinous crimes, I just think that state murder is no better than murder. The American Civil Liberties Union also believes the death penalty inherently violates the constitutional ban against cruel and unusual punishment. I have always liked the bit in J.R.R. Tolkien’s The Hobbit when Frodo says “He deserves death”. Gandalf replies: Many that live deserve death. And some that die deserve life. Can you give it to them? Then do not be too eager to deal out death in judgement”.

Next is free education. In Kenya, where I live, educational standards are low and probably falling, especially since Covid and school closures. Primary education is supposedly free but in practice, primary schools are forever asking parents for “contributions”. Secondary education is not free and I have to provide loans for all my staff who have children at school. The Provincial and National schools are good, expensive and exclude the majority. The rich will send their children overseas, particularly for tertiary education.

Around 43 countries provide free health care, mainly in Europe, Taiwan, Japan, South Korea, Israel and Australasia. National Health Services may not be perfect: the systems are under strain, many grumble, but citizens of countries that provide free health care own something more precious than gold.

So what happens in Africa? When any politician or rich person gets really sick, they are on the next plane to Europe, Dubai or India. President Mobutu spent his last years in France and Belgium slowly dying of prostate cancer. President Umaru Yar'Adua of Nigeria was absent for years in Germany being treated for kidney disease. Last month, President Magufuli of Tanzania was allegedly transferred to Nairobi with Covid, became comatose, was flown to India and died on the plane only to be flown back to Dar-es-Salaam. The official explanation for his absence was that he was busy with affairs of state and that he never left the country.

For ordinary citizens, health care in Africa is dismal. Kenya has around 7,000 doctors (one per 5,000-7,000 people). This compares with Europe (one doctor per 350) or Cuba (one doctor per 120 people). In Kenya, doctors are poorly paid, frequently on strike, and most would emigrate at the first opportunity.

I will now show the contrast between private medicine and state medicine. The other day I was walking my dogs. Suddenly I could hardly move; the pain in my left hip had got so bad. The next day I took myself to a walk-in (or in my case, hobble-in) MRI facility in a local mall and asked for an image of my lower back and hips. After an hour of claustrophobic clanging, whining and thumping, the images were handed over (in return for $350). I telephoned a respected orthopaedic surgeon. In Europe a referral from a doctor would normally be necessary but I don’t have one. After a quick chat, he sent me off for blood tests, an X-ray and an ECG. The ECG was down, so I told the surgeon I would vouch for my own heart. “OK, pop in on Saturday but you must accept there is a risk of contracting Covid”. He was glad of some work as people are avoiding hospitals at the moment.

Armed with a hefty banker’s cheque (50 percent deposit upfront please; personal cheques not accepted), I checked in 7 a.m. to a well-known Nairobi hospital founded by a Gujarati philanthropist in the 1950s. At 7.45 a male trainee nurse twice tried unsuccessfully to insert a cannula in my right hand, by far the most painful part of the next 24 hours. A nursing assistant took over (third time lucky) and I walked into the operating theatre, meeting the friendly Indian anaesthetist of my age. As the surgeon pored over the X rays, I examined the gleaming array of butcher’s equipment. A ceramic-titanium or a cobalt-nickel alloy prosthesis? I chose the former. An obvious advantage of private medicine is that one can chat with and question the physicians. I would imagine that British NHS personnel are generally too busy.

Now, I am a curious person and I want to know exactly what anyone wants to pump into my body. The anaesthetist offered me the choice of a general anaesthetic, epidural or spinal block; I opted for the latter. We then went over the cocktails I was going to be filled with: analgesics, anticoagulants, Xa inhibitors, anti-fibrinolytics, sedatives, anti-emetics and antibiotics. “Right, hop onto the table and let’s get started”. I imagine that in more developed countries one is sedated and wheeled into the operating theatre on a gurney but that surely takes half the fun away. When the anaesthetist started to unwrap a thick 21G needle for the local, I told him I was not obese so he changed it to a fine 26G. Ten minutes after the bupivacaine went in, one experiences what a paraplegic must feel (or not feel), and it is a frightening experience. Then the sawing and hammering started: I had requested to watch it all on CCTV but I was sedated enough not to have been able to concentrate anyway.

Once back in my room, all the hospital staff were delightful, friendly and caring. One of the advantages of having spent decades in the Bush is that I can greet people in at least 12 local Kenyan languages. I find out where they are from, greet them accordingly in their vernacular and as long as they don’t start a long conversation in Boran, Pokot or Digo, there are always shrieks of amusement and surprise. About 24 hours later I asked to be discharged, two days earlier than usual, my excuse being that the longer I spent in hospital, the greater the chances of my contracting Covid. From initial presentation to the surgeon to discharge was 120 hours. For a chronic condition, that surely must be the envy of anyone using a national health system for a hip prosthesis.

The cost of the whole operation was totally out of reach for a casual labourer in Kenya but about one-fifth of what I would have been charged in the USA. The surgeon’s fee was one-tenth of the average cost of a US surgeon for the same procedure.

By contrast, I have a seed collector who works for me from time to time. Before I knew him, he worked on a small dairy farm near Nairobi. He was cleaning out an electric elephant-grass cutter one day when someone accidentally turned it on. I never saw the injury but the local hospital amputated his left arm below the elbow. His family had to pay for the amputation and the hospital would not release him till the bill was paid. He was sacked, tried to get his job back through the Labour Officer, who was paid off by the employer. He went to a lawyer but had no money to sue. No compensation, no support, no possibility of work, nor a prosthesis nor a decent future. C’est l’Afrique. Nine years later this formerly strong 35 year-old is unable to get a job; a one -armed man can do little. He needs $5000 for a prosthesis. I have said I would donate $1000 but several years have passed and he has got nowhere.

There is a minimum wage in Kenya, roughly $5 a day in the vicinity of Nairobi. But I know plenty who are paid under half that for a full day’s work. Unemployment is very high, especially for graduates and especially in the time of Covid. A casual worker would have to work eight and a half years and save 100% of his salary in order to pay for the 24 hours I spent in hospital.

I hope in my lifetime that I will see universal free health care in Africa but somehow, I doubt it. Africa is becomingly increasing indebted to China, so less and less will be available for healthcare and education. Infrastructure is growing apace in Africa, the middle classes are growing but the true benefits of a civilized state…full employment, social safety nets, free education and health care remain a distant dream for the vast majority.