Saturday, 30 April 2011

The Edge of Joy

In 2010, The Lancet published a new worldwide study on maternal mortality showing that for the first time in decades, we are experiencing a significant drop in the number of women dying each year from pregnancy and childbirth globally. The new findings from 181 countries also shows an annual decrease of 1.3% in the maternal mortality ratio (MMR), the ratio of the number of maternal deaths per 100,000 live births.  However, Nigeria moved in the opposite direction of this global trend, with a 1.4% increase each year, from 473/100,000 in 1990 to 608/100,000 by 2008.

But I doubt that the results of yet another study, even if it is published in the pre-eminent medical journal will ruffle any feathers in Nigeria. We are engrossed in our political challenges, and search for daily bread; engrossed in our search for electricity and air time for our phones. We hear these terms “maternal mortality” and “MDG5” so often that they mean very little. They sound technical and complicated and arouse very little emotion in us. Without emotion there is little chance of action. The problem appears too big, too overwhelming.

We must deconstruct this term to enable access to our emotions. When the term “maternal mortality” is used to describe the death of mothers during child birth, we often visualise this as a complication of the birthing process; a medical process that we cannot understand. In reality, this accounts for a small proportion of these deaths. In order to understand the circumstances around maternal mortality we need to understand the challenges we face in our society in a bit more detail.

Imagine a woman in labour. In parts of our country, it is not accepted by society that women should travel alone without being accompanied by her husband. So, she waits for her husband to return to take her to the maternity suite at the local primary care facility. She begins to bleed and deteriorates…

Imagine a woman in labour; and her husband does manage to get her to a hospital. She gives birth, but begins to bleed….it is 8pm. He has to find blood….he has run out of money, the town is dark as there is no electricity….the private laboratories are all closed…

Imagine a woman pregnant with her 8th chid, carrying her 7th on her back. Her husband hardly makes enough money to feed his family; they live together in a two room apartment with shared facilities. She goes into labour, there is no one to look after her other children, her husband is not back from work…
None of the scenarios above are rare in our beloved country. Every doctor and nurse in Nigeria would have learnt to assist surgeries with torch lamps and to do episiotomies with kerosene lamps. We learn to deliver babies with no fall back plan, trusting and praying for the best case scenario. Very often it does not go according to plan A, and one more of our mothers is added to the statistics of our “maternal mortality”.

These are the difficult issues explored in the brilliant documentary “The Edge of Joy”.

The film follows Nigerian doctors, midwives and families to the frontlines of maternal care. Inside a maternity ward, the film chronicles distressed labours, deaths, and miraculous survival.  Outside, lack of blood supply transportation and family planning are examined as causes of the cycle that kills more than 36,000 Nigerian women each year. The documentary explores the nuances and complexities of the risks of child birth in Nigeria in a way that no publication could possibly do so. See a trailer here.

In an interview, the director and producer Dawn Shapiro says;

“I encountered many of the heartbreaking and hopeful stories that underpin this global tragedy, but it was only through the people, the doctors and nurses of Nigeria that I was able to tell them. The roughly one dozen Nigerian doctors and midwives I worked with closely over the course of making the film, didn't push agendas, or act as obstructionists when I asked tough questions, or wanted to follow story lines to their natural conclusions”

Watching this film, the overwhelming emotion was not one of a doctor, or a public health professional, but as a father and a Nigerian. Most of the challenges are mothers who are dying from childbirth complications, and are not those that need great expertise to solve. They are those that require a bit of humanity, political will and resolve. And it is the example of Dr Dikko in the documentary that found an innovative solution to get a blood bank functioning for his busy maternity ward that gives me hope in our country.

Read more about the file here and here.

In the next few weeks, we will bring you some more stories on projects confronting the challenge of maternal mortality in Nigeria.

Saturday, 23 April 2011

Death by Service

The past week has been a difficult on to endure for many Nigerians. From the optimism of elections to the depression of post-election violence. With a heavy heart we re-collect our one year of service to the fatherland through the National Youth Service Corps programme. It appeared to be a masterstroke in innovative thinking to ask corpers to become ad-hoc staff for the Independent National Election Commission for the elections. But  no one quite prepared us for this....for death by service.

In the aftermath of the elections in Nigeria, several young Nigerians like Ikechukwu and Okpokiri below have been murdered in the service of their country. Like all of us who have had the luxury of tertiary education in Nigeria, they were sent to another part of the country to serve and promote our unity. They wore their khaki pants and white tshirts proudly, swearing allegiance to our federal republic, flagging their caps in camp, serving the communities and their country.

On Nigeria Health Watch, we mourn them but also ask ourselves one simple question;

What is the collective mental health of a people that are capable of such violence?

As we search for answers to the political challenges in our society, we must also search for answers to the more fundamental issues. What is it that makes us human, that enables emotions of empathy and love, that creates societies of peace and co-existence. How can we recreate our common humanity in peace and co-existence? We wonder why our leaders are quite and the press timid. Where are the voices of peace? Where are the real leaders in our society that will stand up and reflect the principles of Ubuntu - our interconnectedness - the essence of our being human.

How can we create the society we seek....together?

REST in PEACE guys... 

Thursday, 14 April 2011

Iyabo Obasanjo loss and the National Health Bill

Iyabo Obasanjo, veterinary doctor, daughter of our former president and former senator of our Federal Republic famously lost her seat in the Nigerian Senate in last weekend's elections. What has this got to do with our health sector you might be wondering? Well, the former senator was the Chair of the Senate Committee on Health. Those of you that have kept faith with this blog for the past 4 years will notice our recurrent referral to the National Health Bill that has been stuck in our legislative system for 6 years (previous posts here and here). Iyabo Obasanjo had a unique opportunity to take on this cause and drive the health bill to passage. She had an opportunity to be a real advocate for the health of the Nigerian people and a hero to many of us. She controversially took her committee on health on controversial retreats to the serene environments of Ghana to discuss our health bill eluding EFCC's investigation. But sadly, she had little time for the bill in her last few months in the Senate, when it needed one final push to get it through during this legislative period. So, our National Health Bill remains paralysed and will await the next cohort of senators. Dr Iyabo Obasanjo will be remembered by many in the health sector as the Senator that failed to pass the health bill as Chair of the Senate Committee on Health. What a missed opportunity. 

Why is the Health Bill so important? One of the critical factors holding the development of our health sector is blurred responsibilities for providing for our health care across the various arms of government. The bill, in its present format is not perfect by any means, but anything is better than the impasse the sector is currently in. Without a legislative framework to make progress, the sector has remained in the dark. Contained in the health bill, in between the legal speak are the following critical innovations.

1. The establishment of a National Tertiary Hospitals Commission, a corporate body which will among other things establish minimum standards to be attained by the various tertiary health facilities in the nation and also to inspect and accredit such facilities, set standards and criteria for allocation of funds from the Federal Government, monitor their utilisation, collate, analyse and publish information in relation to tertiary health.

2. The establishment of a National Primary Health Care Development Fund that will be be financed directly from the consolidated fund of the Federation, with 2% cent of its value, with 50% earmarked for the provision of primary care via the National Health Insurance Scheme and the other 50% for drugs, infrastructure and human resources for primary health care to be managed by the National Primary Health Care Development Agency through State Primary Health Care Boards.

3. Legal duties on a health care provider: A health care provider, health worker or health establishment shall not refuse a person emergency medical treatment for any reason. Making this explicit by law means that I can sue any health care provider that fails to provide care in an emergency. This that can lead to a fine of N10,000.00 or to imprisonment for a period not exceeding three months or to both fine and imprisonment.- and of course a criminal record and its consequences.

The biggest risk to the National Health Bill at the moment is that a huge amount of funds have been earmarked for management by the NHIS, an organisation that has failed in its mandate in financing the provision of health care for the Nigerian people and is currently embroiled in a leadership quagmire as the Executive Secretary sued the Federal Government of Nigeria for allegedly retiring him prematurely. The Federal High Court in Abuja granted the current Dr. Waziri Dogo Mohammed, the current Executive Secretary of the NHIS an interim injunction restraining the previous Minister of Health, Professor Osotimehin from interfering with his job as Executive Secretary, pending the determination of a motion he filed challenging his removal from his tenured appointment as Executive Secretary of the NHIS. While this is going on - the NHIS has remained another part of the Nigerian puzzle.

In all the excitement of the elections, we had a short bout of hope when it was intially annouced that Dr Ibrahim Oloriegbe had defeated Dr Olusola Saraki in the senatorial elections in Kwara, Ibrahim will be remembered as the first executive secretary of HERFON that drove the development of the National Health Bill to its present state. Sadly, this was not to be. We hope that Ibrahim continues to seek the opportunity to serve his people.

Finally, lets see what the elections hold for the Nigerian people. Maybe, just maybe we will elect a leader that will give the health sector the priority it deserves....and a new group of senators that will take our health a little more seriously.

Sunday, 3 April 2011

My visit to UNTH – a dream deferred

I was recently in Enugu, and visited my medical school – the University of Nigeria Teaching Hospital (UNTH).  I had lunch in the residents’ common room with a colleague from our medical student days who is now a senior registrar (the final stages of specialist training). I'll call him Emeka for the purposes of this blog. Emeka has to stay in the system, so to allow me a forthright account; I agreed to keep his name anonymous. 

Chikwe: Bros how are things in UNTH

Emeka: My brother, this place has stood still in time. Yes, it is true that we have moved from the old cramped, Coal camp location to the permanent site in Ituku Ozalla, but apart from that, little else has changed. While we have more space for ourselves and the patients, the distance from Enugu has come with its own challenges. There is so much potential here but sadly as you can see all around you very little progress.

Chikwe: How has the leadership in the hospital been in the recent past?

Emeka:  Don’t even ask! This place is in dire need of new and fresh leadership. At the moment, as Nigeria is voting for new leaders, we too are in the process of electing and selecting new management as Dr Mba’s tenure as Chief Medical Director comes to an end in May.  The past eight years have just been “business as usual” in UNTH. As the world changed around us, we are stuck in the past.

Chikwe: Ah! Those are strong words oh!

Emeka:  Yes oh. There is a raging battle between colleagues of Enugu State extraction and “the rest of the country” for who will produce the next CMD. The two camps are split down the middle and not a single doctor of Enugu state origin accepts a new leadership from the other camp or vice versa! The Enugu state camp has nominated Dr Ozoemena of Surgery while the “rest of the country” nominated Dr Obidike of Paediatrics. There is hardly any discussion among our apparently highly intelligent colleagues on the vision of these two colleagues for this once-great institution. Not a single colleague has crossed the ethnic line publicly! Not one…

Chikwe:  Well, finally it is the Federal Government who will appoint the CMD. Maybe it is best to appoint from outside the hospital for the sake of peace.

Emeka:  Maybe, but we saw what happened when Prof Gomwalk was appointed as VC in UNN, because of a similar challenge at the time.

Chikwe:  But Emeka, let us leave the politics of UNTH leadership. How is clinical care? How is our Centre of Excellence for Cardiology.

Emeka:  My brother – the centre is in a coma. You remember all the open-heart-surgery we saw in our days as medical students; all that is history.  The centre is almost history. Prof Aghaji has left for Abuja too. You must have heard that his brother passed away about a year ago. The fence of his house fell on him! Nigeria…my brother life here is not easy oh!

Chikwe:  Wow…but what of every day practice?

Emeka:  We are hanging in there oh. We all seem to be going through the motions. There is absolutely no motivation among colleagues.  We come to work, do the best we can, prepare for our professional exams with whatever materials we have and then we all go to our private hospitals to work in the evenings.

Chikwe:  But how are the patients that make it to Ituku Ozalla?

Emeka:  Chikwe, it is not easy here. The place is so disorganised and patients suffer a lot, a lot! They have to walk around all over the hospital. Every small item has to be paid for independently, so patients walk around from the laboratories to the pharmacy to the wards and then start afresh. Patients suffer incredibly! You do not even want to hear about the quality of the food patients are served. Our colleagues in surgery have to struggle for hours to get theatre organised for a single case.

Chikwe:  I saw an accreditation team here for the pathology department, is it a routine visit?

Emeka:  Ah…noo! The whole department lost its accreditation since 2005, so no candidate from UNTH can go for the professional exams in pathology. As the accreditation team is here, colleagues in the department have been running around collecting materials from everywhere. They actually had to borrow a fire extinguisher from the PEPFAR office! Once the team leaves, we return all the equipment and pray for the best! Naija no easy my brother…

Chikwe:  And what is this I hear about medical students? Over 400 students in a single set! That can’t be true, as we were hardly up to a hundred in one set a few years ago.

Emeka:  Chikwe times have changed. I pity the students because there is no way they can get the training they deserve. There are hoards of them in every ward. The medical school’s accreditation was lost when the Medical and Dental Council of Nigeria found out about the numbers and this has now been restricted to 150 per year moving forward. But, the medical school is now desperately seeking means to reduce the numbers in existing sets. But yes….that is what we are dealing with!

Chikwe:  But how are the professional exams? Are our guys passing and making progress?

Emeka:  The pass rates for all the professional exams have always been historically poor from UNTH, and we are always quick to blame ethnicity. But Chikwe honestly I am not sure oh. Sometimes a set of colleagues go to Ibadan for exams and not a single one passes, at best a handful. We moan a bit here and there…but nothing changes. I have not been there myself, but I hear that Lagos University Teaching Hospital (LUTH) is changing, and even University of Ibadan (UI), but here in Enugu we are in the wilderness.

Chikwe:  What of all the consultants?

Emeka:  You want to get me into trouble? Let me pass my Part 2 first oh! Very few of them are dedicated to patient care in UNTH. Almost all of them have thriving private practices across Enugu. The distance to Ituku Ozalla has also led to patients preferring to see these consultants in town, even if it costs a bit more. Go around Enugu, and see for yourself. Almost every major hospital is managed by UNTH consultants. Some of us registrars have our own too, else we work with our consultants. The struggle continues.

Chikwe:  But Emeka, there must be some good stories from UNTH. It is the University of Nigeria after all, in all its pride and glory!

 Emeka:  Yes oh, there are a few bright lights. Do you remember Dr Oguonu in the children's' emergency ward? He was a registrar in our time. He has shown an amazing dedication to his job, and has tried to ensure that there are systems in place to support the management of emergency cases that come into casualty. It is now the case that patients resist being transferred out of casualty! But you know our country. Other colleagues are getting jealous and there is grumbling in the system about the parallel systems being set up. So you see, even when one tries to be innovative there is opposition.

Chikwe:  So what are your own plans? Do you plan to stay here after your training and grow?

Emeka:  You must be joking. This place will kill my soul. There is no joy here, no energy, no motivation. Nobody really cares. We do the least we can to keep the system moving…we have a big name and a rich history, but that’s about it. Maybe the new leadership may turn things around but I cannot wait…once I get my Part 2, I am out of here. There is so much to do with the profession we have Chikwe. We owe it to Nigeria, and to humanity. UNTH will not provide the platform I need, so I will go and look for the right one or create it.

Chikwe:  I am with you Emeka but if this is happening to the pre-eminent public sector health institute in South East Nigeria, what hope is there for the rest of the health sector?

Emeka: The politics here is too much. I can’t do it. You guys all left the country and now you come back to ask all these probing questions and make all of us feel bad.

Chikwe:  No Emeka, we are all guilty….we all are. We hope that change will come but some of us  have to be the change we seek.

Emeka: E go better… my brother, e go better.