Monday, 30 March 2009

The case of the missing bride

Missing bride?

Yes...the bride in the health sector has to be the patient. The person who it is all about, the centre of attraction.

The absence of concentration on the best interest of the
"patient", or "the population" in implementation of health policy and health projects in Nigeria is a central concern to Nigerians, especially Professor Adetokunbo Lucas (Former Director of the Special Programme of Research and Training in Tropical Diseases at the World Health Organization in Genevaand Professor of International Health at the Harvard School of Public Health)

Professor Lucas made the case made eloquently
at a recent conference on health in Nigeria; Nigeria: Partnership for Health.

In most other countries in the world the PATIENT is central to health policy. Whether it is about the basic package of care that is guaranteed, the waiting times before treatment, access to life-saving medical interventions, or vaccination coverage ...the PATIENT is always central to policy.

In the past 10 years of renewed democracy in Nigeria, this has sadly not been the case...buildings and professional interests have been central to our health policy. We are either building primary health centres or we are renovating teaching hospitals. We are either suppling CT scanners or MRI machines. We are in and out of strikes defending our professional interests. Even in the appointment of the last Minister of Health; the debate in the public space was whether it should be a "doctor" or a "pharmacist".

Picture: New hospital in Bayelsa State

Where is the patient in all of these?

This will be a central theme of the next series of posts on Nigerian Health Watch. Where does the patient fit into the thinking of our leaders in the health sector.

We welcome your contributions!

Today we will start exploring several stories in our dailies. I will not comment further on any of these. Read them as written by those affected...personally affected. It gives you a glimpse into their reality...

How the Health Care System in Nigeria killed my Sister
I arrived in Nigeria on the 30th of January to be greeted by a deteriorating airport with no usable lavatory facility. I proceeded do my usual running around, transact some business, visit family and friends but unfortunately decided I was going to see my baby sister at her doctors office at Onikan, Lagos. Little did I know I was never going to get a chance to see her ever again. Details on

Nigeria: Abandoned and Deserted Patients - Luth Groans
THEIR situation is pathetic, their condition is pitable. Scattered all over the Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos, are patients of all types and of every category. Adults and children; male and female or young and aged. Details in the Vanguard

A Struggle to Stay Alive
The doctor said I need more than three million Naira to do the operation overseas. Now I am appealing to Nigerians to assist me. My father died since when I was eight years. My mother has been carrying the burden of my life. I don't want to die. Details in Thisday

Citizen Bello and Nigeria's healthcare system
The death of Mrs. Ajoke Bello who was recently delivered of sextuplets and two of the babies has not only brought to limelight again the poor child and maternal health records in Nigeria, it has also exposed the general decay in the country's healthcare delivery system. 32 year old Mrs. Bello who was successfully delivered of sextuplets through a Caesarean operation (C-section) died at the Olabisi Onabanjo University Teaching Hospital (OOUTH), Ago-Iwoye, Ogun State 24 days after being delivered of the children. Details in the Financial Standard

Monday, 23 March 2009

Onchocerciaisis on the verge...

If you have been to the headquarters of the World Health Organisation, you will notice this stature right in front of the main building. It represents the efforts made to control one of a disease many in the West might never have heard about called River Blindness.

The African Programme for Onchocerciasis Control (APOC) is heralded by many as one of Africa's most successful public health programmes.

One of the keys to its success is that it by-passes government!, delivering the once-a-year treatment; Ivermectin through community volunteers directly to the affected populations. This approach called Community Directed Treatment is now being replicated for Vitamin A, de worming medicines, insecticide-treated bed nets and potentially several other public health interventions. The programme itself was innovative in being the first that negotiated an unprecedented pledge from the manufacturer of Ivermectin; Merck to provide an unlimited supply of the drug, for all who needed it, for as long as it takes.

The current director of the African Programme for Onchocerciasis Control (APOC) is a simple Nigerian lady; Dr Uche Amazigo. The article linked here describes her as "The scientist with a large heart for Africa's poor". I recently had the opportunity of watching Dr Amazigo at work, steering the WHO bureaucracy, negotiating with partners and funders, motivating her staff and managing the large network of colleagues in several countries on whom she depends on make APOC succeed.

River the common name for the most important clinical syndrome caused by onchocerchiasis. It is the world's second leading infectious cause of blindness. It is caused by Onchocerca volvulus, a small worm that breeds in fast-flowing rivers and can live for up to fifteen years in the human body. It is transmitted to people through the bite of a black fly. The worms spread throughout the body, and when they die, they cause intense itching and a strong immune system response that can destroy the eye. About 18 million people are currently thought to infected with this; approximately 300,000 have been permanently blinded.

As with many other illnesses, we have a simple treatment that is entirely free to the patient. The challenge is to deliver it to them for the 15 consecutive years required for an individual to clear the disease. As with other diseases where a "simple" treatment is available there are obvious pressures to push for eradication. Many believe that following the efforts of the Carter Center and its partners, Guinea worm is on the verge of eradication. If that works...who knows....will Oncho be next? Others think that the "cross" of the target "eradication" is too heavy to carry, as anything less will be perceived as failure.

Watching Dr Amazigo work over a week....I cannot help but think of Chinua Achebe's epic book; The Trouble with Nigeria". On the first page, Achebe says bluntly: "the Nigerian problem is the unwillingness or inability of its leaders to rise to the responsibility and to the challenge of personal example which are the hallmarks of true leadership.

I think not....I think that the real tragedy with Nigeria is the paucity of opportunity for real leaders to emerge in our political space, while Nigerians provide the leadership we so dearly miss at home... in every ither corner of the world.

If only Nigerian children will read about people like Dr Amazigo..if only....

Wednesday, 18 March 2009

Medical Accidents: Are doctors still burying their mistakes?

Our recent blog on the words of the Minister of Health regarding the attitudes of doctors and nurses to work in public hospitals has inspired this piece by our guest contributor Kingsley Obom-Egbulam.

Its a must read!

Like most people, we all went into 2009 with so much expectation. If you are a Christian in a country like Nigeria, in line with the usual “prophetic declaration”, your pastor must have given the year his or her name, thus changing the year 2009 to “ year of endless harvest”, “year of sweat- less success”, “year of soaring on eagles wings”, and this popular one, “year of laughter”.

I am not too sure what the year was called in my place of worship. But whatever name we called the year, was almost eroded by a terrible news we got less than one week into 2009.

“Have you heard the sad news?”,that seems like my happy New Year greeting that morning. I had just settled down to business that day which incidentally was my first day at work in 2009 and my colleague, who must have suspected my need for some updates sauntered in and announced the unexpected news. “Sister Nwugo died last night”.

You can imagine the reaction that followed the bombshell.

Nwugo Okoye was until her death, the Head of Corporate Communications at Etisalat-one of Nigeria’s mobile telecommunication companies. Before moving to Estisalt, Nwogu had worked as Manager in charge of Internal Communications at MTN, this was after over a decade of robust practice in the advertising industry.

She was good!

Nwogu’s fruitful and vibrant life was cut short after a failed Myomectomy ( an operation done to remove fibroids while leaving the uterus intact).

She went into the theatre certain she would make it. She could afford to have the surgery done anywhere in the world. But she chose to have it here. Was it a gamble? Did Nwugo commit suicide by opting to remove a disturbing fibroid here in Nigeria –a simple surgery many other women have had and came out successfully in Nigeria? Was she just another addition to the growing list of medical accidents we all have to put up with in Nigeria?

Less than ninety days before Nwogu’s death, somewhere in London, Ada Effiong had gone for an even more complicated surgery. Considering the nature of the surgery, she didn’t want to gamble, or so it seems. Unlike Nwugo, Ada never thought she would make it. “I had to settle all outstanding issues, my will, and other issues that needs to be resolved, something just kept telling me I wouldn’t make it; so I didn’t want to leave any problems when Im gone”.

Ada made it. She is still alive , hale and kicking.

A public health physician recently said that in resource-challenged settings like Africa, more patients are likely going to die in hospitals due to medical accidents occasioned by negligence than the impact of the illnesses they are suffering from. This, according to the doctor, is a global fact, even if it appears questionable and only applicable to developing countries. But is this a rule in Nigeria or an exception? Can this pass for a rule that must be obeyed by hospital users and people who will have cause to see any doctor and be eventually admitted or it is an exception we should not bother about?

In the wake of the June 12 Celebration last year, a few Nigerians in Lagos were mourning and preparing to bury one of the best female voices on radio -at least in the last decade. Adetutu Badmus, former Radio Nigeria Network news caster, fantastic compere’ and gifted voice-over artiste had her voice on over half of all the radio commercials produced in Nigeria. She had just moved from Radio Nigeria to LTV 8 as Head of Programmes and Content Management. Many of us were already looking forward to a revival in that stations programming policy and consequently its quality of programmes. All of our dreams suddenly turned into nightmares.

Tutu died in the labour room of a tertiary health institution in Lagos, less than a year after her wedding.

Again, did she commit suicide by opting to have her baby in Nigeria since she could afford to have the baby abroad?

Incidentally, Tutu’s service of songs was officiated by Gbenga Adeoye ,a Pastor with the Seventh Day Adventist Church, who lost his wife a year ago in circumstances similar to that of Tutu. Adeoye said the doctors who attended to his wife had a case to answer. Though they’ve buried their mistake, Adeoye believe “God will judge them for their negligence”.

Dr. Badmus, Tutu’s elder brother said he is not just sad that he lost his kid sister , but that he is sad that his sister died a needless albeit avoidable death. And being a doctor himself, he certainly knew the undercurrent of Tutu’s death.

Without casting aspersions on our health system or passing a vote of no confidence on our medical personnel, truth is: we are fast building a health system that swallows its patients.

It is becoming dangerous not to have some working understanding of basic diseases and possible therapies and (depending on your faith),a team of prayer warriors or Alfas interceding on your behalf before seeing any doctor these days. You may end up being a cadaver( a corpse good only for teaching medical students in teaching hospitals) if God doesn’t show up on your behalf and avert an accident or negligence.

Three of my friends lost their dads to this chain of medical accidents and it continues to form their attitude towards medical care in Nigeria. The first one, her dad suddenly started convulsing(or so it seems)and was about to kick the bucket. He was taken to the hospital and they found out after some tests that his blood sugar level had risen far beyond normal. He was immediately given some medication to bring down the sugar level at last close to normal. But the drug had an adverse effect on the man .He was given more than he required. He lost his mind and was like that until he passed on less than two weeks after.

The other two are similar even though they were in separate hospitals that were hundreds of kilometers apart. They both had hypertensive dads who were also diabetic .And in both cases, their dads had malaria and were rushed to the hospital after some days of trying to find out what exactly was wrong. They were admitted immediately they got to the hospital and were infused with dextrose because they hadn’t much energy, food and water in them due to severe loss of appetite. Nobody bothered to know their medical history or find out whether they were diabetic or not. Can you believe that?

Of course, they both passed on ,one of them died less than 48 hours after being admitted.

Another pathetic case was that of a patient-an old man ,who was diagnosed of hernia. He needed to be operated upon. The surgeon wanted to make it snappy and get it done with in no time so he could attend to other personal perhaps more important matters. To achieve this, the patient was generally anaesthetized-this was to put him to sleep and save him from experiencing the pain of the surgery while it lasted.

But it back fired.

The patient responded badly and the complication that arose was not bargained for. Considering the age of the patient, and the fact that he was also diabetic, some medical experts believe that he should have been locally anaesthetised. By this, the pain would only been relieved around the part or region of the body where the surgery would be carried out while the patient remains awake to see what was going on. That would have reduced the amount of anaesthetics in the old man’s system and consequently the length of time he would have spent out of this world.

The good news is that this patient is alive today and kicking-thanks to the hospitals massive investment in ultramodern medical facilities.

It is still too early to forget that renown Attorney and human rights activist, Chief Gani Fewinhimi also had a taste of these of these medical accidents. Our beloved Senior Advocate of the Masses and of Nigeria, still flies in and out of London for treatment.

Fawehinmi is scared…yes scared for you and I who may not be able to fly abroad like him and the president when we are about to join the growing list of victims of medical accidents in Nigeria.

Gani, a living legend and a firm believer in the future of Nigeria and its potentials, had to escape for his dear life to London contrary to his patriotic principle. Gani had been on treatment for pneumonia in a highbrow hospital on Victoria Island.

Gani’s treatment was informed by a misdiagnosis. He go to know this when he arrived London mid last. After several checks in London, he was confirmed to be down with cancer and had to be placed on cancer treatment. It is not clear how much damage the initial misdiagnosis had done on his health, but the truth is: if Gani had died in Nigeria before he was flown abroad chances are that doctors in that Victoria Island hospital would have told Nigerians that he died of pneumonia. And we may never get to know the truth. Never!

If this could happen to the likes of Gani and even the president(before he had to run to Germany)what then is the fate of other Nigerians?

Millions of medical mistakes are mostly premised on wrong diagnoses. Leading most times to unnecessary surgery and sometimes failed surgery which may lead to death.

In cases where the diagnoses are right, negligence and lack of respect for the patient is said to be the main enemy and when this enemy shows up in the course of treatment someone has to pay the price most times it is the ultimate price.

How do we stem the tide of medical accidents in Nigeria? How do we ensure that doctors are held responsible for negligence when a life is lost needlessly in their hospitals or clinics? How can we even prove these cases in the first place? How alive is the Nigerian Medical Association(NMA)and indeed other bodies regulating medical practice in Nigeria to the responsibilities of ensuring patients protection and standard of practice?

The Lagos State government stirred the hornets’ nest last year when it passed the Corona’s bill into law .The law ,among other things was supposed to (at least, on paper) keep doctors in check and put an end to questionable deaths of patients in hospitals. Of course the law also contained aspects considered injurious to medical care-aspects which well meaning doctors say can prevent them sticking their necks to saves lives already at the brink of death.

For now, one reality we cannot run away from is the fact that many Nigerians have died (and would still die)simply because their cases were poorly handled in hospitals. Some have gone unnoticed and in the case where the victim is a prominent person, some questions may be asked. But like all cases, no one will be held responsible or brought to book. How can we end this unusual epidemic confronting ignorant Nigerians and their families lost to medical accidents? How long will doctors continue to bury their mistakes while pilots die with theirs?

Too many questions. When would the answers come?

Kingsley Obom-Egbulem, a social entrepreneur and communication specialist is Chief Creative Officer, Health Communication and Development Initiative(HCDI),Lagos and Editor-In-Chief, MANHOOD Magazine.

Sunday, 15 March 2009

HIV access to treatment and prayer houses

It was a busy afternoon when the text arrived from my colleague whom I had met working on HIV in the UK " Can you please recommend a reputable HIV support organization in Nigeria? A relative of a friend has just been diagnosed in Nigeria"

I wasted no time in passing on the details of Journalists Against AIDS whose website and e-forum continues to be such a valauable resource, as well as PATA, the organization founded by the redoubtable Rolake Odetoyinbo who thankfully had a list of treatment centres and support groups on their website

The next day I had planned to send a text to find out how they had got on, but the pressure of work meant that I was unable to. The next morning I woke up to another text "Thanks for the links but the patient died yesterday, apparently she had been in a prayer house for the last 2 months"

I was chilled to the marrow but also angry, remembering the many patients I had seen in clinics ten years ago whom I had had to break the news that they had tested positive to HIV when there were very few treatment options available in Nigeria. Now as a result of activism and advocacy, treatment was now available and yet people were still failing to take up treatment, preferring to head for prayer houses

Granted, this patient may still have died even with treatment, but there was also a good chance that they could have survived, but the chance was never taken....

Who will stand up to these prayer houses? Who will help our people to help God to help ourselves. We cannot leave everything to God....not if he has given us the brains to solve some problems for ourselves...

Photo copyright International AIDS Society

Friday, 13 March 2009

Strong words by the Minister...

"You are killing the patients and it is our duty to entrench discipline if our health system must go back to what it used to be.”

These were the very strong words of the Minister of Health, Professor Osotimehin at the inauguration of the Governing Boards of Federal Hospitals, Professional Regulatory Agencies, and other parastatals of the Ministry of Health in reported by the Daily Trust

Who was this directed to? The doctors and nurses paid to save our lives!

Finally....someone has the courage to speak out.

Try walking into a public hospital in Nigeria these cannot help than to be shocked at how slow any one responds to anything. It really does not matter if you are bleeding from your aorta...nothing, nothing brings out the sence of urgency. Finally the gauntlet has been dropped.

...accusing them of habitually abandoning their patients for personal pleasures.

...government could no longer afford to sit by and watch health professionals in hospitals treat patients with ignominy for a job they had sworn to perform and were paid to perform.

...the insensitive attitude has led to many patients seeking alternative care to the detriment of the once-robust healthcare system in the country.

....We have come to a point where doctors on call are not just found; nurses do not perform their duties; and other health workers do not think that they have a duty at all.

... it is our duty to entrench discipline if our health system must go back to what it used to be.

...He challenged professional regulatory bodies to wake up to their responsibilities as the Boards should help hospital management take a new direction in healthcare delivery.

But finally...are these empty words or prelude to real change..only time will tell.

Wednesday, 11 March 2009

Professor Akunyili, Mrs Yar Adua and maternal mortality might wonder what our Minister of Information and our First Lady; Hajiya Turai Umaru have to do with women dying around childbirth (maternal mortality).

Well... they both don't seem to know how bad things are in Nigeria.

In February 2009 both ladies were at the launch of UNICEF’s 2009 State of the World’s Children report UNICEF officials released figures of infant and maternal mortality rates of its member-countries.

Nigeria, with official maternal mortality rate of 800 per 100,000 births was not surprisingly, at the bottom rungs only second to war-torn Congo as the world’s most dangerous place for infants and expectant mothers.

  • Akunyili promptly got up to reject those figures. They did not, she said, reflect the reality "on ground".

  • Our beloved First Lady is reported as saying that she had visited hospitals in the course of her pet project and at each place she was told that not one woman had died during childbirth! “Come out with new reports,” she reportedly admonished UNICEF, “We do not want those reports again.”!!!!

For those in the know, this report says nothing new. It only reinforces existing facts. These figures are contained in the National Demographic Health Survey from 2003 published by the National Population Commission of the Federal Republic of Nigeria.

What the report also says that might help these important ladies understand the figures include...

  • 37% of women had a live birth with no antenatal care
  • 13% of children 12–23 months fully immunized (BCG, measles and 3 doses of DPT and polio)
  • 100 per 1000 life births die during infancy

And if you think that this is as bad as it gets..think again. The graph below is from the Federal Ministry of Health, shown at a recent conference on health in Nigeria.

So are the National Population Commission and the Ministry of Health part of the "conspiracy" to give Nigeria a bad name?

I remember an "argument" I had with a friend. He too blamed UNICEF, WHO, UNDP for saying that Life Expectancy at Birth in Nigeria is 47 years. His argument: There are many old men and women in his then can our life expectancy be 47!!!? But that is my can afford to be challenged by statistics.

The first step in solving any problem is understanding there is a problem, then the next step is understanding the problem. We need to tell ourselves the truth regarding our health sector. The indices of maternal mortality and infant mortality are not just indices for the health sector but indices for a country's development.

Lets accept our reality...then work slowly to make it better. Unfortunately to moved indices as infant and maternal mortlaity in a country with a population of 150 million will require a bit more tha pet projects and re branding excercises.

Friday, 6 March 2009

Diagnosis: Meningococcal Meningitis

I cannot forget one of 'my' patients during the first medical clinical rotation under Professor Nwabueze at the University of Nigeria Teaching Hospital. You could not imagine a death more painful. This young man of about 40 years had full blown meningism with a neck stiff, high unrelenting fever, confusion, coma and eventual death.

Nigeria belongs to a region of the world where meningitis is most prevalent occuring in often large epidemics; commonly referred to as the "meningitis belt". These large epidemics which occur in a cyclic mode due to herd immunity (whereby transmission is blocked when a critical percentage of the population had been vaccinated, thus extending protection to the unvaccinated). This form of meningitis, caused by type a of the bacteria is generally referred to as Cerebro-Spinal Meningitis (CSM).

There have been several reports in the media about an ongoing Meningitis outbreak in Northern Nigeria. This cycle has been expected for some time.

- On the 9th of February, WHO announced that there have been 1364 suspected cases of meningococcal disease in Nigeria including 108 deaths (case-fatality rate: 7.9%) in 19 out of 35 states and Abuja....t

- Now on the 3rd of March, the Minister of Health Professor Osotimehin goes public
saying that 5,323 cerebrospinal meningitis (CSM) cases had been reported in various parts of the country with 333 deaths in 22 states. (case-fatality rate: 6.3%) must have be considered quite serious that tonight, the 5th of March 2008...our beloved NTA International had as their lead story on Network News at 9pm! Believe it or not...this came before they went through their usual nightly routine on who had visited the President, Vice President, Senate President, Speaker and all their respective First Ladies....

...Professor Osotimehin faced the Nation telling us:
  • He had just returned from a tour of the affected states
  • The states are leading in the control of the outbreak
  • He stated that 6 million doses of the vaccine had been procure (WHO says 1 million to Nigeria on their website - date 04/03/09)
  • He expressed satisfaction at the response
  • The strategy of the FMoH was to "continue and sustain"

We have come to accept these epidemics as inevitable. Despite repeated coverage of the ongoing legal battles with Pfizer and the Kano epidemic of 1996, (for which Pfizer has negotiated a N11.2bn settlementt)
,we as a country have not confronted confronted our reality when it comes to CSM and other infectious disease. They will not go away!

While we are HAPPY that the Minister is taking the lead on this...we need to start now preparing for the next cycle (large outbreaks occur apporximately every 3 years)
  • Antibiotics that can cure meningococcal meningitis...but patients need access to health care services rapidly. A case fatality ratio of 7% is way too high and an indictment on the health services provided.
  • Yes, a vaccines against the disease exists—they are “polysaccharide” vaccines—and they have limitations. They don’t work in children under two and thus leave the most vulnerable unprotected.
  • Because polysaccharide vaccines do not provide long-lasting immunity, the reactive mass vaccination campaigns must be repeated outbreak by outbreak, therefore requiring skilled expertise.
  • We therefore need a national centre for disease control as in most other countries in the world, to train and maintain the skills necessary to prepare and respond to outbreaks like this.
  • To support this we need a Field Epidemiology Training Programme as in many African countries...Ghana, Zimbabwe, Uganda, South Africa, and Kenya
  • In the future we can and should manage outbreaks like this without the help of European Commission Humanitarian Aid Department (ECHO), Médecins sans Frontières and UNICEF as is the case in this outbreak...
The good news is there is hope for a vaccine that will give long standing immunity against Meningitis A...which will hopefully be available soon. But having a vaccine is one thing...getting it to people that need it is another. With our vaccine coverage rates for childhood vaccines averaging at 30% (data from 2003) then we do have a lot of work to do....a lot!