Square One

Richard Smith reviews Nigel Crisp‘s  Turning the World Upside Down: The Search for Global Health in the 21st Century in this week’s BMJ. The striking comment in the review was an explanation for health workforce brain drain in Africa:

His case for “turning the world upside down” might begin with the stark facts that Africa has 25% of the world’s burden of disease but only 3% of its healthcare resources and 1% of health workers. North America, in contrast, has 3% of the disease burden but 25% of healthcare resources and 30% of health workers.

Rich countries are plundering health workers from poor countries, and one reason that’s happening is that rich countries have exported their outdated health systems and ways of thinking—meaning that health workers in poor countries are trained inappropriately and feel more comfortable in rich settings.

It has just occurred to me that developing countries might indeed be in the best position to redefine the health worker for the 21st century in the light of America’s super-expensive over-doctored system, and the sheer effect of grappling with chronic illnesses on health systems globally.

The full review is here.

It is itself a surprise to me that we are responding to the issue of the alleged Nigerian suicide bomber/terrorist as if it was totally unpredictable. We want to condemn it, we are disappointed by what Umar is alleged to have done and the added shame and disrepute that has brought upon Nigeria, but it would be wrong to suggest that there are no fundamentalist strains in Nigeria. They abound.

The recent Boko Haram incident, and the way muslims in Northern Nigeria reacted to the 2005 Danish cartoons of Prophet Mohammed (PBUH) by setting churches on fire suggest that we must have been breeding this kind of people, and we are probably more capable of breeding them with possibly little outside influence than we presently imagine.

A series of troubling but interesting events happened in close succession, within the space of two years, when I was a student at Obafemi Awolowo University, (OAU) Ile-Ife. For those who are not very familiar with Nigeria, OAU is arguably the most Yoruba and also possibly the most politically active and intellectually progressive of Nigerian universities.

Obafemi Awolowo Hall (popularly called Awo Hall) is well known as the most politically active, hilarious, fun loving and liberal residential hall within the university. Awo Hall also has a long standing tradition, dating back about twenty years or more, of the free screening of pornography videos in the hall’s TV Room every Friday evening. There is incidentally a make shift mosque just across the lawn from the TV Room in what used to be the kitchen attached to a dinning cafe where students used to eat when the Nigerian government provided free food for university students. The tradition of Friday evening porn predates the existence of the make shift mosque, which according to the university was even an illegal creation in the first place. Suddenly one Friday evening the leaders of the Muslim group in the hall stormed into the TV room and seized the DVD player. The incident eventually degenerated into a free for all fight that resulted in a two-week university closure.

There was another occasion when a girl was beaten up for dressing “inappropriately” while visiting the hall (Awo is a male residential hall). The muslim brothers retreated into the mosque after the onslaught and they wouldn’t allow anyone who wasn’t a muslim to approach for questions and a demand of apopogy. They held sticks and other weapons, prepared to attack the uninvited. It was strange and scary. I had to step in, having been a rather good friend of the Awo Hall mosque as I had been spotted entring the mosque to take part in prayers, and having subsequently attracted a couple of the more senior members of the mosque who tried to convert me to Islam, albeit unsuccessfully. Thankfully, we were able to get them to apologise in the long run, an act that eventually that brought the mattter to rest.

A third one occured when a girl was married off to a fellow student by fellow students within one of Mosques in the university without the knowledge of either party’s parents. The girl subsequently decided to cut off all communication with her family. After several weeks of failed attempts at reaching her, the girl’s parents had to visit the university to confirm what had happened to their daughter. She had been transformed from a regular muslim lady to one that covers her face, she was already pregnant and she wasn’t going to see her parents when they eventually visited.

I once had a “friend,” a Nigerian who told me that he would kill me in the event of a holy war! He wasn’t joking.

Mild as these incidents were, what they show is that for these to happen in the liberal south, at the very bastion of southwestern Nigeria liberalism, you can imagine what possibly goes on in the north where some states already practice the Islamic Sharia legal system.

I don’t think that Umar did what he is alleged to have done simply because he is from a rich, privileged family or from northern Nigeria. He simply had good access to radicalising influences, or is it the other way round? There are thousands of Nigerians, I’m sure, who would go the same way if only they had the same kind of access Umar Farouk Abdulmutallab had, and we should not be oblivious of this important fact as we discuss this unfortunate incident.

I still remember the shock when I realised that the practice of homeopathy was funded within the National Health Service (NHS) in England. I was taking a lunchtime stroll when I came across the Royal London Homeopathic Hospital, which as it turned out was one of the hospitals within the UCL Hospitals NHS trust, which also included the hospital to which the Institute of Neurology where I was studying at the time was affiliated. I almost felt ashamed.

It was particularly shocking because the United Kingdom does have a reputation for science and rationality that is hardly equalled elsewhere in the world. The experience however made it less shocking for me when I got to Sydney, Australia and found lots and lots of alternative practices, with all sorts of interesting and grand names, structured to deceive and confuse with legitimate science. However, I doubt that like in the UK, any is funded from the public purse of Australians.

Two weeks ago, I met a black woman from Jamaica (although born in London and raised in Auckland). She was the first black person I walked up to and spoke with in Sydney, and the first and only person ever to have referred to me as ‘brother’ in the restricted black folk sense of the word. It was rather strange. I had never been a ‘brother’. There are not many in Australia.

We got on the bus together. She had studied ‘alternative/complimentary medicine’ in her youth and had also received training in homeopathy. Much of the rest of the trip was spent discussing the claims of homeopathy, during which she argued that homeopathy was much like vaccination. I was so mad, but out of courtesy I had to change the topic immediately. It reminded me of Raymond Tallis‘ 2007 Sense about Science annual lecture where he said:

…and this is how it is with junk science that borrows the terminology of science, without any sense of its true meaning, and of the massive interconnected hinterland of facts and concepts and even uncertainties behind them.

…and so we have treatments such as ‘reflexology’ which expropriates a well-established, indeed central, concept in biological science, and uses it to label treatments that have no biological foundation whatsoever.

…and ‘homoeopathy’ which, being in Greek, one of the languages of science, sounds very scientific but is based on magic thinking that would shame a six year old child.

…they domesticate terms by uprooting them from a complicated nexus of hard-won concepts.

Whenever I see those Sydney shops or offices, what comes to mind is how successful alternative medicine practice/movement is in Nigeria as well, and how they feed on pretty much the same sentiments. I reckon it must indeed be a universal phenomenon. Thankfully, we are not yet at the stage where the Nigerian government will fund an alternative medical practice, but I bet we are not that far either. I am almost certain of it that the movement will soon have a ‘scientific’ arm made up of people trained as much as to be able to throw terminologies around but not quite as much as to have any deep, nuanced understanding of them.

Here is an excerpt from an advertorial on the popular Doctor Akintunde Ayeni of Yem-Kem International Nigeria Limited:

…he [has] invested resources – time and money to visit renowned herbal homes in India, China, Australia, Japan and Pakistan. In similar vein, [practitioners] of alternative therapy in those countries visit him, here in Nigeria, to exchange notes. The result of these research efforts is manifested in the emergence of our three products namely (1) Blood Cure, which a blood purifier and immune boosting herbal medicine (2) M & T Capsule which is an effective herbal medicine for all chronic fever and (3) Energy 2000 which is a powerful herbal medicine for sex ability deficient patients.

The words again: ‘research’, ‘immune’, ‘capsule’, ‘doctor’, ‘discover’, et cetera. It is also interesting that Australia has its place among the visibly oriental countries that Akintunde Ayeni has visited.

John Diamond, who before his eventual death had his hopes of cure from cancer falsely raised by several alternative medicine practitioners did put what would be my summation very beautifully: “There is in reality no such thing as alternative medicine, just medicine that works and medicine that doesn’t…There isn’t an ‘alternative’ physiology or anatomy or nervous system any more than there’s an alternative map of London which lets you get to Battersea from Chelsea without crossing the Thames.”

So how do you define medicine that works? Well, the same way that Artemisinin made its way from the fields of central China to clinics everywhere chloroquine resistant Malaria is treated.

Jo Stephenson writes in this week’s BMJ about different approaches to equipping doctors for management and leadership roles. This is how we need to start thinking in Nigeria now. We cannot continue to leave the management of our hospitals and health care institutions and system in the hands of those who are not trained to manage them, no matter how senior or clinically experienced.

I sent this article to Dayo Osholowu, a sports physician in Nigeria who replied by saying: “We have to embrace the responsibility that is falling on us or someone else will. The ownership and management of health service insitutions will fall on an elite corp of financially sophisticated management experts. Lets join this corp with open arms and the venture will reward the few.”

He went ahead to paraphrase a quote from Dr Strangeglove, where General Jack D. Ripper says: “Clemenceau (himself a medical doctor who later became French PM) once said that war is too important to be left to the generals. When he said that, 50 years ago, he may have been right, but now, war is too important to be left to the politicians. They have neither the time, the training, nor the inclination for strategic thought.”

Health care management indeed in the same vein, is too important to be left to doctors/clincians. Here are excerpts from the BMJ article:

However, many people would like to see management skills introduced earlier in doctors’ training. In America there are a growing number of dual MD/MBA courses on offer. Harvard set out to create a truly integrated programme, explains Richard Bohmer, medical professor at Harvard Business School.

Students concentrate on medicine for the first two years but do a management internship in a hospital or healthcare firm between the two years. In their third year they continue medical training as well as doing several management courses, including looking at management problems on the wards.

“Students are getting clinical experience. At the same time we’re teaching them about some of the organisational issues they’re seeing,” says Professor Bohmer.
During the fourth year they do an MBA with a clinical rotation and in the fifth and final year they complete their MBA and clinical rotations.

………………..
Meanwhile other US medical schools are introducing leadership elements into graduate medical education, such as Dartmouth Medical School’s leadership preventive medicine residency. It is a two year programme on top of a traditional three year clinical residency, offering the chance to earn a masters degree in public health and gain skills to lead change and improvement in health care.

The programme includes clinical leadership rotations and a major practical assignment in which trainees are expected to apply what they have learnt to a real health service situation.

………………..
Many doctors combine management with clinical work, but in Australia and New Zealand it is possible to be a registered specialist in medical administration by becoming a fellow of the Royal Australasian College of Medical Administrators. Doctors with three years’ postgraduate clinical experience can go straight into a three year training programme providing supervised medical management experience in posts such as deputy medical director.

Alternatively, senior doctors trained in other specialties can gain fellowships in a minimum of 18 months depending on previous experience.
This approach has boosted the status of medical managers. Fellows can command higher salaries, and in some states fellowship is a requirement for directors of medical services.

“There is that feeling that a doctor who has gone into administration has gone over to the dark side. Making it a recognised vocational skill certainly goes a long way to dispelling that myth,” says college president David Rankin

The full article is here.

This is an article from Nature about how the recession has dampened donor enthusiasm for scientific research in Africa and here is an excerpt about Nigeria:

Countries that don’t depend on aid are also struggling. In Nigeria, the drop in demand for oil and gas, exacerbated by a stricken banking sector, means that private donations — a major source of funding for Nigerian universities — are slowing. “In the past, a conference like this would have a lot of Nigerians coming, supported by industry grants. We don’t find many today,” says Oye Ibidapo-Obe, president of the Nigerian Academy of Science in Lagos. Nigeria’s government won’t pick up the slack left by the drop in private investments, Ibidapo-Obe adds. “Research is not seen as the major driver of the economy.”

I am not sure where Nature got these assertions from, or why Oye Ibidapo-Obe said what he is quoted to have said, but this certainly reeks of falsehood. Someone is either making up stories to mislead Nature, or Nature itself is doing the  embellishment. Nigerian banking sector, and industry grants being a major source of funding for Nigerian universities? This is just so false.

I was invited – quite soon after the then new ER in OAU Teaching Hospital, Ile-Ife was completed about five years ago – by Chibuzo Odigwe to co-write a short article on commission for the studentBMJ about ‘the Nigerian Emergency Department’, which was to go alongside an article on a newly refurbished ER in the US. I remember in our discussions we had to work out a middle ground between ‘telling it like it is’ and being ‘economical with the truth’, and also having quite similar train of thoughts as Damilola Onikepe Owolabi expresses here in this guest blog post on a new ER in the Lagos hospital where she is presently working as pre-registration house officer, written exclusively for Square One:

The New ER in Lagos

Emergency room medicine is the highlight of movie medicine. Glamorous, fast paced, it displays the skills of medicine, its infrastructure and puts its personnel in hero light. Your heart beat doubles in rhythm as you watch every move to save that patient, and as the balance of the scales tilt back towards life, your radial pulse slowly normalizes and with it a compensatory increase in your mind for the value of medicine.

Yes! ER medicine is “it” only it literally doesn’t exist in this country. Internship has been traumatic as I watch countless lives slip out of a world with technology so advanced it lies on the brink of cloning human organs.

For lack of a simple nebulizer a 37 year old asthmatic is no more. And I really have never and probably will not soon see a defibrillator, an integral part of TV ER. Adrenaline to kick a heart back to normal takes at least 15 minutes to procure, and for want of funds to buy a grey cannula, easily correctable shock lingers till the damage cannot be undone.

It hurts so much to know how much you could achieve with simple basic things: drugs, equipment, extra personnel. How does one nurse man a surgery ER with more than 20 patients. And the classic trademark scrubs, forget it! Part of the ghastly experience of watching people barely survive is having relics of bloody stains on any part of you.

The most amazing thing, the federal government-run government hospital where I’m presently interning completed a new ER two months ago. Slowly but gradually it rose and when the commisioning date was set, in typical Nigerian style, work tempo took on a whole new pitch. Painters scrambling about, technicians banging on new split units, it was to be the ultimate A&E. The ceremony ended, the building looked good, painted. The standard marble nameplate was unveiled, and since then all activity has ceased.

Its doors are not yet open and numerous questions abound, like who will staff the new building? There is literally not much more equipment inside to get better work done anyway. This monster shell of a building doesn’t improve our blood bank services. It will not hasten the tardy laboratory technicians to do tests; neither will it fill up syringes with much need resuscitants and antibiotics. It will not defibrillate failing hearts or provide the required number of trained personnel to improve survival. And unfortunately it will not make more affordable to its usual customers what they need to keep on living.

Quite frequently our national policies on diverse things are reviewed. Budgets are re-written for health, and our verbose bureaucrats make numerous promises and pledges. It is quite irksome to see year in and out our problems have not changed: “We need more funding from developed countries, and better means to implement policies.” “We need the statistics of infectious diseases.” We need to train and retrain our personnel please.” These are the lines towed by content of reports from WHO, African Development Bank and other proposals from diverse health organizations.

We have prioritized and re-prioritized amongst re-doing many things, but every time I look around me, I see a system falling to pieces. So as not to be cynical I admit we do indeed have rebel fighters in our midst, people who will improvise, substitute, work until they die, but how much do they really achieve with an almost abject dearth of everything.

My new ER is but a facade of what it should really be because within itself, its architects and managers, it lacks the substance to achieve the reason why it was built which is exactly my problem with reviewing policies in Nigeria. They have become routine, empty words, quixotic promises, sometimes derived from well analyzed data, but unadapted to our local needs.

And even when great minds have worked to customize the solution to our peculiar realities, it seems like what we do is document, give speeches and set up committees. Many defunct committees exist, many noble ideas have never been translated into deeds. We do not need words of change, we need people to get their hands grimy, their thoughts realistic, not to fear the world of politics, and to make decisions and take actions to start off the slow process of change.

“The struggle of man against power is the struggle of memory against forgetting.” Milan Kundera

Bullying. The dominance, the arrogance, the vanity of it all. Think of the medical student who has no other response than to keep his head low. You are always on the line. You have to make the right impressions, or at least avoid making the wrong ones.

What mostly baffles me is that most, if not all consultants must have been irked, piqued, offended, disgusted, even exasperated while they were bullied as medical students. So why is it that some still end up as irritating as they are? Wondering what on earth fuels the vicious circle, I came up with two hypotheses.

Memory in different colours

“Life is not what one lived, but what one remembers and how one remembers it in order to recount it.” Gabriel Garcia Marquez

Do memories of these wrongs merely dissolve into a fast receding past? Memories, of course decay. Does the mind simply reconstruct the past in an overly positive light and people forget that they ever suffered these same wrongs? Nostalgia is always in the business of cleaning off the bad and indelibly printing the good in our memory. Or does time, the slow passage of time, simply dull their sensibilities, even reverse all they had held to be true?

The distracting slings and arrows of middle age may contribute to the loss of youthful idealism. It’s so easy to consider these changes in perspective an advantage of thinning hair; the gradual mellowing down and placidity that is often confused with wisdom.

Does relativism just take over? What is right or wrong anyway? Isn’t that all we’ve been fed with in medical school? That is the old-time tradition of medical practice. End of story. Or is it the savage case of the oppressed becoming the oppressor as he takes what he has suffered out on someone else?

Power calls to power

“Power calls to power, and the brutality of power…evokes a conspiratorial craving for the phenomenon of success.” Wole Soyinka

I noticed a particularly interesting, though surprising trend while editing my class’s final year book — a greater proportion of my classmates, usually the most brilliant, who considered themselves likely to end up in academic medicine filled in the names of the most tyrannical consultants in the hospital as their most admired teachers. It was a rude awakening for me.

Wole Soyinka once suggested that one of the reasons why despots find it easy to remain in power is “the self-willed ignorance of brilliant men who bend their skills and intelligence to ensuring the continuity of power by rationalizing and even applauding the crudest barbarities of power.”

Although it might ordinarily have sounded far-fetched, this seems the most plausible explanation I could place my mind on. Such affinity, as Soyinka cites, is in close parallel to the love a slave girl has for her master, clearly shows that power indeed calls to power. This perverse identification with power figures may, in reality, be self-identification. The viewpoint that validates and justifies the activities of power may, in turn, affirm the existence of the student.

Eternal vigilance
“Eternal vigilance is the price of liberty.” John Philpot Curran

Medical practice will continue to be steeped in a quasi-terrorist quagmire that thrives on the fear of failure or loss of professional recognition until we all choose to combat this criminal hierarchy, first and foremost, individually. The way out lies in developing a critical awareness of what goes on around us everyday, and learning to constantly interrogate our own individual motives and feelings.

To keep our memory intact, my simple suggestion is that we resolve to keep written records of such events as we pass through medical school. This is the only way these events can remain pure in our memories and ensure we never repeat them. And if you’ve not yet suspected, that is exactly what I was trying to achieve by writing this article – taking notes.