Thursday, 21 July 2011

My Chief - The Honourable Minister of Health

In 1996, I started my one year housemanship programme in an unlikely location;  Abia State University Teaching Hospital (ABSUTH), Aba. While not necessarily renowned for its academic or clinical excellence at the time, the hospital in its early years of becoming a teaching hospital had sought some excellent, young, enthusiastic consultants to drive its clinical evolution. Unlike the older teaching hospitals, with large cadres of doctors in training, in Aba - it was the house officers, a few medical officers and the consultants who provided care. So we worked hard, had a lot of responsibility, but we learnt a lot, very fast. While at Aba, I was lucky enough to work with 3 consultants whose work ethic, ethos and attitude shaped the rest of my career. Just as I was starting my first medical job, they were starting their first consultant positions. These 3 colleagues were Dr C Adisa, Dr C Kamanu and Dr Onyebuchi Chukwu.  Dr Chukwu left Aba in 2000 for  Ebonyi State University Teaching Hospital, Abakaliki, where he was appointed Professor in 2007, as well as being Chief Medical Director/Chief Executive Officer between 2003 and 2008. In April 2010, he was appointed Minister of Health for the Federal Republic of Nigeria and reappointed in July 2011.

In medical practice in eastern Nigeria (and this might be the norm across the country) we refer to our professional seniors as "Chief". In the context it is used, it is an incredibly powerful word. It confers respect while maintaining an informal undertone fulfilling two important constructs in clinical practice - acknowledgement of clinical seniority while maintaining collegial friendliness....but I digress. Those of us that passed through Prof Chukwu's tutelage in ABSUTH, will surely agree with me on his clinical qualities, integrity and respect for the patient - even in the often difficult circumstances we faced in Aba. However, there are two areas that I am not yet in a position to offer a great deal of insight into (as it was too early professionally to think about these at the time) - his managerial skills and professional courage. But, for the sake of 150 million Nigerians, I hope that he these in the bag too. These two factors will be, in my mind, the most important attributes that will be needed for him to succeed as Minister of Health in our Federal Republic.

I will not bore you with an account of the state of affairs of our health sector. Follow us on Twitter @nighealthwatch to read the continuous stream of tales of woe from Nigerians that have had to access our public sector health services at all levels. It is difficult to understand how things were left to get this bad. Our facilities are in a mess, colleagues are disenfranchised, 30% of our medical schools have had their accreditation withdrawn by the Medical council. Our previous president did not hide his lack of confidence in our health sector in the last few months of his life, importing even the ambulance that took him on his last journey from Abuja International Airport to the State House in Abuja. Our capital city has no functional emergency medical response service. Eighty percent of all the funds allocated to the health sector in our country goes to a handful of tertiary care facilities, while we pay lip service to primary health care. Health care professionals are constantly on strike as they jostle for more pay and status. Our National Health Insurance Scheme has not managed to cover up to 2% of Nigerians in its 20 years of existence and our National Agency for the Control of AIDS only funds treatment for 5% of patients on antiretrovirals in Nigeria, as we leave the rest to the benevolence of the US President's Emergency Fund for AIDS (PEPFAR). After 8 years of crawling through our tortuous legislative process,  the  "new" National Health Bill has eluded presidential accent. Things are so bad that Professor Chukwu said in his own screening process by our Senate that our pride and joy - the National Hospital in Abuja is a "National Hospital" in name only. Alas, I did promise not to bore you with the state of affairs in our health sector.

But we must not just complain, but also offer solutions.

It is my contention that the biggest challenge facing our health sector is not equipment, infrastructure, money or human resources, but  its management. The managers of our health sector have been making breathtakingly bad decisions. Our managers spend years negotiating pay packages for health care professionals with no contracts relating to what these professionals are expected to deliver for their salaries. Our hospitals are managed without any clinical or financial performance indicators or targets, or metrics of performance. With no functional data management system and no referral system, management is blind and based on instinct. In the past 8 years several contracts running into billions of naira have been granted for the procurement of CT scanners, MRI scanners. A particularly painful example was the procurement of a linear accelerator- a piece of equipment that costs about $5million - N750,000,000 (not including installation, or contract inflation) delivered to my alma mater: the University of Nigeria Teaching Hospital (UNTH), Enugu. A linear accelerator (like the one in the above photo) is used to deliver radiotherapy, a method of treating cancerous tumours by targeted beams of radiation which can rotate around the patient's body to deliver the radiation from different angles. This 'investment' in UNTH has never functioned...ever. It has been serially vandalized and its shell still lies there, tucked away in a room in Ituku Ozalla. I can imagine that the story is not different for many other centres. The opportunity cost of failures like this is simple - people die. Not just from the cancers that this would have treated, but of 'simple' things like bleeding during labour for lack of blood, or lack of oxygen in our theatres because the money that would have been used for this was spent on the linear accelerator. Management is our greatest challenge.

As bad as things are,there lies the greatest opportunity one can hope for in the health sector in Nigeria - to be the leader that turned this ship around. But it will take courage....lots of it. The health sector has unions that have the toughest bargaining chip available to mankind - the ability to take lives by not working. No other profession has such power. It is because of this that we, doctors take oaths to above everything "do no harm" on graduation from medical school, and it is because of this that you so rarely hear of health professionals striking in other countries in the world. Not so in our Nigeria. There will be strikes and counter strikes as the health professionals fight over a few dollars more and status. Appointments of Chief Medical Directors of our Teaching Hospitals are almost akin to gubernatorial elections. Campaigns start years in advance as teaching hospitals divide along interests, ethnicity and privilege. Prayer sessions are held and Babalawos are visited.  The sector will resist change and resist vehemently.
It will take courage, lots of it.

Herein lies the challenge my Chief faces. He has a great challenge and a great opportunity. We will continue to celebrate him as we did in Aba, but this time it will take more that integrity and clinical excellence - it will also take clear management, leadership and courage. We wish him and Nigeria well.

Saturday, 9 July 2011

Memories and Hopes of South Sudan

Today is a special day - so we will make an exemption from our focus on health in Nigeria. Today, Africa adds a new independent country - South Sudan.The significance of this moment is difficult to describe. But sadly, very few of us Africans have had the chance to travel on the continent. South Sudan is an abstract entity to many of my friends and colleagues. Ill reminisce on my first and only trip to South Sudan...and ask you to join me in wishing this country the best of luck as it emerges into nationhood. 

In May 2004 I was part of an international team that responded to an outbreak of Ebola haemorrhagic fever in South Sudan.Growing up in Nigeria, and having traveled the country quite a bit, I thought I knew what poverty looked like. But, nothing quite prepares you for South Sudan. Firstly, getting there was an adventure on its own as we flew from Nairobi to Lokichogio to Juba and finally to Yambio, flown in this small aircraft by  a team of South African pilots....looking down at the beautiful landscape of a ravaged land....

In Yambio, South Sudan, we worked with whoever we could find locally, walking through the villages looking for patients that might have symptoms. As is the case in these outbreaks, separate teams dealt with surveillance, case management, social mobilisation and logistics. The astuteness of the local medical staff and the rapid international response resulted in relatively few deaths in this Ebola outbreak as had been the case in several previous ones.

To support our control efforts we recruited some recovered patients to join our work, two of whom joined us in our social mobilisation and health education campaigns. One of them was a bright teenager in his final year of secondary school who had lost his mother to the Ebola virus. He was quickly integrated into the social mobilisation team and came with a powerful message, which he delivered eloquently. He told his story through our loudspeakers carried around the villages, in churches, schools, and markets. Crowds came out to listen to the child who had survived the deadly Ebola virus. His presence reinvigorated the team, strengthened our message, and contributed substantially to controlling the outbreak.

With the outbreak over, we packed up to leave. Our former patient and colleague promised to keep in touch, and he did. Initially I replied to each mail enthusiastically, trying to inspire him to rise above the enormous obstacles in the path to success in South Sudan. However, once I was back to my daily routine, investigating small outbreaks of gastrointestinal illness, South Sudan quickly became a distant memory. But his mails continued; he sought help to go to university; he wanted to be a doctor, to be like us. There were no universities in South Sudan, and Khartoum was out of reach for those in the south. The best hope was to move to Uganda, a long trek indeed. Sadly, I could do little more, my replies became less frequent and eventually stopped.

At the time, news had just broken that peace was close at hand between South Sudan (or New Sudan as they call it) and Sudan. I prayed for my teenage friend and for all the children in South Sudan. Decades of war and unrest had robbed them of a chance of an education...robbed of a fair shot at life. I prayed for the people of Darfur, that they too may have peace. I prayed that they might be spared the ravages of Ebola epidemics.

The week we left, the community was preparing for a visit by John Guarang, then the political leader of South Sudan who had only recently signed a peace agreement with the Government of Sudan. There was a palpable hope in the community for peace and I left with a much better understanding of the conditions and circumstances of the people of South Sudan of my age who had never known peace in their lifetime.

Today as South Sudan celebrates its independence, I think about my friend, with a more hopeful tone. Once, there is life, there is indeed hope. I hope one day to return to vibrant progressive country and that they avoid the mistakes my country, Nigeria has made with its oil. - will they do it?

Sign at the hospital entrance

Aluta continua...

Most of the contents of this piece first appeared in the British Medical Journal, under the title - Once there is hope, there is life. At the time, Chikwe Ihekweazu was a fellow of the European Programme for Intervention Epidemiology Training (EPIET).