Learning about health care in africa: a physician's experience in lagos, nigeria

Learning about
health care in Africa:
A physician’s experience
in Lagos, Nigeria Africa has long been a destination for medi-
cal and religious missions. As far back as the mid-1400s, Britain and other European countries sent missionary teams into the interior of what was at that time referred to as “The Dark Continent.” In later years, medical by Larry N. Smith, MD, FACS teams worked to understand the diseases that
were killing not only the native inhabitants of this region, but also the members of various ex- In the late 1800s, compassion was not always the driving force behind humankind’s desire to understand and treat sleeping sickness, malaria, and yellow fever. The value of Africa’s natural resources and the developing concept of social Darwinism were likely the most compelling rea- sons for understanding, and eventually curing, In spite of the imperialistic intent of some past missions to Africa, I felt compelled to join the long roll of medical missionaries who went to Above: Lagos students in their uniforms, heading to school.
VOLUME 97, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Expectations
Having read of David Livingstone, pioneering medical missionary from Scotland, and with vi- sions of Noble Prize Laureate Robert Koch, MD, in my head, the mission team from Trinity United Methodist Church of Gainesville, FL, arrived in Lagos, Nigeria, on July 3, 2010, with a broad range of responsibilities. The medical team was to staff a medical clinic at the West African Theological Seminary (WATS). I had come prepared to look for and diagnose Madura foot, leishmaniasis, sleeping sickness, malaria, and even dengue fever. The clinic provided care for a diverse group—from PhD can- didates who were in school at the seminary and their family members, to local people who came from Entrance to Dr. Ekhakite's private clinic and hospital.
many socioeconomic levels. Walking to the clinic on the first day, I noticed the cleanliness of the children and their clothes, and the meticulous manner in which mothers cleaned their homes—and how that Throughout my daily work, I kept waiting to contrasted so sharply with the overall sanitation of evaluate a patient with an unusual disease process, the neighborhood. Young women walked to work or but instead, I found myself treating every general school in polished high-heeled shoes dodging water medical condition that American physicians treat and mud puddles all the way. Cars and motorcycles today. Over the course of my eight days in clinic, the navigated potholed roads to avoid deep puddles team saw patients from three weeks to 85 years of age, and open ditches on either side of the road. People performed routine physicals and wel -baby visits, and urinated and defecated in public with abandon.
reassured the worried-well. Multiple patients were The team arrived at the clinic and followed the experiencing peri- and postmenopausal symptoms. directions of Florence, the matron who was organiz- I counseled patients on family planning issues and ing the operation. Florence told me that “the drums explained the ovulatory cycle repeatedly for young had been sounding” for some time before our arrival, married couples. Concerns about sexual health were and she expected we would have busy clinics. She common, and counseling again played the biggest role in these situations. Prostatitis, or BPH, was common and Hytrin was a commonly prescribed drug. For these patients, prostate levels were easily obtained in Expecting to see unique tropical diseases that I had only read about, I set out to see my first patient. It was Hypertension was ubiquitous, and, in many cases, then that I began to realize that I was about to begin the patient knew about it but had little interest in practicing the true art of medicine. I have to thank staying on medications. I came to recognize as nor- my medical school professors, my residency training, mal that most of the patients had what appeared to and my 25 years of medical practice for giving me a be elevated diastolic blood pressure. This seems to strong understanding and appreciation for physical be in keeping with data about African Americans in diagnosis. At first, I believed that my medical impres- sions would comprise the diagnosis and that there Adult-onset diabetes was another common but would be little opportunity for confirmatory testing. growing diagnosis. The carbohydrate-rich, low- To a certain extent that was true, but I quickly learned protein diets and overweight-to-obese Nigerians that sophisticated laboratory testing and diagnostics prompted many sessions on the merits of diet and were close at hand and reasonably priced. All health exercise in order to control weight, blood sugars, and care services (provided on a cash-only basis) seemed blood pressure. The challenge, the team discovered, very responsive to the patients’ needs.
was convincing patients to take the medications rather 25
FEBRUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS than use the herbal “remedies” prescribed by the local the state hospital for biopsy and a possible skin graft.
shaman. Routine exercise is not a traditional practice During our off hours, I made a trip to visit the local for the average hard-working Nigerian.
Sikenu Hospital, owned and operated by the physi- Over the course of the trip, the team encountered cian who staffed the WATS clinic one day a week. A some interesting pathology. I found two patients graduate of the Nigerian University of Medicine, Dr. with aortic stenosis, both having a mid-systolic, II/ Ekhakite was very knowledgeable and well-trained. VI systolic ejection murmur confirmed on an echo- He was kind enough to show us around his facility, cardiogram. Two potential prolactinoma patients and I was impressed by the volume and breadth of were evaluated and diagnosed. Both women were his general medical practice. He had a small lab to postpartum and had not breast-fed for 18 months but test for malaria and typhoid (white out test), and he were still lactating and could not conceive. Laboratory performed 2-D ultrasounds with some skill. In his op- testing, bromocriptine, and referral were my only erating room, he performed appendectomies, hernia recourse, but consultation with Moses Ekhakite, MD, repairs, cholecystectomies, cesarean sections, prosta- informed me that prolactinomas were quite common. tectomies, and minor procedures. Dr. Ekhakite’s re- I treated foreign bodies in ear canals and found covery room was adequate, and his four-bed inpatient several children with acute otitis media. One child had ward served the community well. We referred a five- chronic otitis with a small anterior perforation that year-old child to the hospital who, for two days, had had started draining. She was started on Cortisporin been suffering from diarrhea, nausea, and vomiting otic suspension and Augmentin elixir. The patient with moderate dehydration. She was evaluated and was referred to an otolaryngologist for follow-up treated by Dr. Ekhakite with IV fluids, antiemetics, and bowel rest. Typhoid testing was negative but she Despite my best efforts, I was unable to find and was treated for 24 hours with IV antibiotic therapy. treat a patient for malaria, typhoid, or any other Follow-up visits revealed her gradual improvement.
tropical disease. Many patients are treated for malaria The highlight and low point of my physical diag- simply based on symptoms and not on laboratory nostic experience came when I evaluated a professor documentation. This unrestrained treatment protocol teaching at the seminary. She was of Northern Eu- and the over-the-counter availability of Chloroquine ropean descent, blue-eyed, blonde, and fair-skinned. probably account for malaria’s near-universal resis- She denied any family history of tremors, although tance to the drug in Africa. Overuse of malaria pro- she had been out of the country for many years. She phylaxis has added to the progressive resistance from complained of a mild tremor in her hands and tired- the most fatal malarial species, falciparum. Europeans ness. Further questioning revealed that she had lost do not recommend prophylaxis, particularly for travel her zest for her mission. She had noted some difficulty in urban areas, because the risk for contracting the sleeping, swallowing, and recent constipation, and her gait had slowed. A physical exam revealed bilateral Near the middle of my stay, I finally came across resting hand tremors with subtle pill rolling that a patient who potentially had cutaneous leishmani- improved with movement. She had a resting head asis (CL). Four years earlier, she had been treated bobbing or tremor. Her tongue had a mild tremor, for an anterior tibial compartment syndrome with and her reflexes were asymmetric but present. Finger fasciotomy and drainage. The wound healed slowly to nose normal, gait slowed but improved with walk- but never completely resolved. The girl stated that it ing. Upper extremity range of motion demonstrated started from a bug or fly bite on the back of her calf. classic right greater than left cogwheel rigidity.
History revealed that she had been treating it with Why was diagnosing a patient with Parkinson’s gentian violet (purple staining) and penicillin powder disease the highlight of my experience? Several years with no success. Her wound was classic in appearance ago, I, too, was diagnosed with Parkinson’s. As a for CL, with a whitish covering, fine granulation result, I was in a position to provide the patient with tissue underneath, and rough patchy edges. There information and insight. I spent time discussing my were several options available for treatment, includ- clinical impression with her, the various treatments ing Amphotericin-B, Diflucan, and Paromomycin. available, and what she may expect in the future. We The first trial was for Diflucan, given its safety and discussed the pathophysiology of the disease and de- availability in the country. She was also referred to cided on a trial of Sinemet 25/100. I saw her five days VOLUME 97, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS later and she was already feeling better. Her mood, gait, and tremor had improved. I did convince her to seek a second opinion from a neurologist back in her hometown in the U.S., which she arranged.
The most logistically difficult case I encountered was a patient whom Dr. Ekhakite referred to me. The patient was a 36-year-old female, G3-P2-A0, 29-week gravid with biopsy-proven metastatic lymphoepithe- lioma in the left neck. She was a non-smoker and non- drinker and was asymptomatic except for a 3-4 cm swelling in the left tail of the parotid, post-auricular area. A computed tomography (CT) scan revealed only the left neck masses with no other nodes or neck masses present. A chest CT was negative, and a biopsy had been reviewed both in Nigeria and in Britain, with findings consistent with Epstein-Barr virus and lymphoepithelioma. Her case was complicated by her pregnancy. Dr. Ekhakite suggested steroids to ac- celerate the child’s surfactant pulmonary maturation, with the aim of delivery in several weeks followed by definitive treatment for the woman. After further consultation, it was recommended that she undergo a biopsy of her nasopharynx, base of tongue, and a needle biopsy of left parotid. She was also scheduled for high-resolution CT of her head and neck, with attention to the nasopharynx with bone windows. She was referred to the U.S. for treatment. A letter to the U.S. consulate for an emergency medical visa was submitted; however, due to embassy issues, costs, and expedience, the patient elected to seek treatment Final impressions
I had been conditioned, over the years, to believe that Africa was a continent where death and disease lurked behind every tree and within every flying in- sect. The reality is quite different. I found few to no unusual diseases in the urban areas of African cities. Lagos, a city of 18 million, has an integrated and com- petent health care delivery system. Pharmacies were adequately stocked with state-of-the-art medicines. Hospitals—although not elaborately designed when compared to such facilities in the U.S—are privately owned and staffed by trained and capable physicians and nurses who have access to reliable medical labo- ratories. None of these facilities would likely meet The Joint Commission’s accreditation standards, but Dr. Ekhakite's operating room (above) and recovery room (below).
all provided excellent care with compassion and had Surprisingly, Nigeria is beginning to experience 27
FEBRUARY 2012 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS growth among those chronic disease processes com- motivated, educated, and capable. I learned a lot from monly associated with Western societies. Addition- my experience there, and I recommend it to all who ally, family planning is becoming a bigger part of have ever wanted to give back in this fashion.
the national dialogue, as men now seek vasectomies. This is a big cultural and emotional step for many References
men in Nigeria and other African countries, where 1. Smith LN, Parente ST. America’s Healthcare: Through Igno- traditionally a man’s societal success has often been rance, Bigotry, Poverty, and Politics to America’s Uninsured: measured based on the number of children he has Medicine’s Long Journey. Stanford, CA: Stanford University fathered. All other modern Western methods of birth Hoover Institution (under review for publication).
control are available in Lagos, and while I was there, 2. Watts S. Epidemics and History: Disease, Power and Imperial- women were beginning to use them. Interestingly, ism. New Haven, CT: Yale University Press; 1997:256.
3. Johnson TO. Arterial blood pressure and hypertension in the women, men, and medical community accepted an urban African population sample. Br J Prev Soc Med. expanding birth control measures and family plan- ning methods but uniformly opposed abortion as a 4. Freedman DO. Malaria prevention in short term travelers. birth control method. This evolving acceptance is N Engl J Med. 2010;359(6):603-612.
5. Africa’s population: Miracle or malthus? The Economist. still being met with resistance in other countries on Available at: http://www.economist.com/node/21541834. All of the children were vaccinated and well-cared 6. Groping forward: Nigeria’s new government: One and a half for, in spite of the levels of poverty and poor sanita- cheers for the economy. None for security. The Economist. Available at: http://www.economist.com/node/21538207. Most children attended school and spoke English as well as their native tribal dialect. Education is a priority in the society. Many people were pursuing master and doctorate degrees. Some children would get up at 5:00 am to work and make money to afford school, and then go back to work after school to earn money to eat. Everyone worked because there is little to no social welfare system. Markets where every conceivable service or need was sold would go for miles along the roadside as self-motivated, personally responsible people cared for themselves and their families. No one went hungry. With the collective work ethic exhibited by the population, it is easy to understand why they want to come to I do not want to give the impression that Nigeria Dr. Smith is a retired
is a perfect place. No, it has its problems, including massive government corruption with theft of bil- lions and payoffs to the local police and government officials, which are as routine as buying a Starbucks coffee in the U.S.6 Corruption is just part of doing business there, and it explains why the roads and the sanitation systems are dysfunctional. The judicial system is now beginning to investigate and prosecute officials for this behavior, and local governors are try- ing to provide better infrastructure using the courts to prosecute those individuals who fail to do their jobs. Nigeria has the potential to become an effective economic and medical leader in Africa if the country’s leadership chooses to allow it to do so. The people are VOLUME 97, NUMBER 2, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

Source: http://www.operationgivingback.facs.org/stuff/contentmgr/files/49b4f1b086a4d60eaf0c85e919999ccb/pdf/2012.02smithln.pdf