Sunday, January 31, 2010

Medical education in Nigeria

Gentle readers, forgive me for not writing more about Haiti. Though I volunteered, I have not yet been asked to deploy. Those of my colleagues who have done so, and who are in a position to comment on low-resource medicine in Haiti after the earthquake, are understandably busy and not yet able to do so.

Let's turn instead to Nigeria. Dr. U.V. Okafor teaches at the University of Nigeria Teaching Hospital in Enugu. (Famed author Chinua Achebe taught at the same university.) He has written about critical care in sub-Saharan Africa and commented on the dire shortage of nurses there. He kindly agreed to answer my questions about medical education in Nigeria; what follows is a lightly edited version of what he had to say. His words reveal a great deal about the issues that face practitioners in low-resource countries, including the emphasis on teaching the physical exam; the lack of a strong emergency medicine paradigm; brain drain; payment problems for physicians; the need to attract and retain only medical personnel, but also allied professionals like engineers; and the use and misuse of federal and international funds.

Italics and hyperlinks are mine.

A little background? Basically, medical education in the country is patterned after the British system. Nigeria is of course a former British colony, attaining independence in 1960. Physical examinations are greatly emphasised in our medical education because of a large rural population without access to tertiary care centres with modern equipment. Nigeria’s Human Development Index (HDI) progressed from low to medium in 2009. And that is good news for us, and credit must go to the rural-based doctors (they will get rural posting allowances in the new salary scale).

How do you teach students? I am a senior lecturer in anaesthesia and intensive care. Medicine is a 5-6 year programme in Nigeria, and the medical students undertake a four-week posting in clinical anaesthesia, in addition to classroom lectures. Usually I use PowerPoint presentations for my lectures to medical students. As a member of the curriculum committee of the medical school, I tried to include more credits in emergency medicine, but it is still a novel concept in the country.

A word on residents' training? I also train residents in anaesthesia. The residency programme usually takes 4-7 years, depending on one’s progress. The final examination of the programme involves a dissertation or a case series, and that usually prolongs the training. Successful candidates become Fellows of the Medical College of Nigeria, or Fellows of the regional West African Postgraduate Medical College....[The WHO surgical safety checklist is] not currently in use [at UNTH]. I got it from the WHO website and hope it will be standard practice soon.

Where do residents go to train? Though [UNTH is] one of Nigeria’s premier teaching hospitals and its centre of excellence for cardiothoracic surgery, her best graduates usually pursue postgraduate training overseas, in the US or Britain, and mainly for economic reasons. Most of the first-generation consultants were UK-trained with a sprinkling of US and Canadian fellows. I think the North American-trained specialists rarely return to the country. To reverse this sad trend, the Nigerian government recently increased the salaries of medical workers, buoyed by the increased oil and gas revenue. The country is the world’s sixth largest producer of crude oil. The new emolument will take effect this year.

What kinds of resources are at your disposal? In early 2007, the hospital moved to its permanent site where the theatre was well equipped by VAMED, an Austrian health care service provider. They installed multi-channel monitors (pulse oximetry, non-invasive blood pressure monitor, temperature, electrocardiography and capnography), and modern anaesthetic machines with low-flow systems. MRIs are avaliable in some federal government-funded hospitals, but maintenance is a problem due to a paucity of biomedical engineers. To the best of my knowledge, PET scanners are not available, being quite expensive for a developing country like Nigeria, which has no health insurance for most of her citizens. Besides, the problems of infectious diseases means funds are diverted towards these areas, and their treatments are greatly subsidized (about seven dollars a month for HAART).

A word on your position as an academic physician? The major problem for those of us in academia is a lack of grants for research work, and we still depend on Western organisations like Wellcome Trust for assistance. When a nation has made billions of dollars from oil revenue, it certainly got into some hands, but funding education doesn’t seem to be on their minds. With a former university lecturer as President, we hope that will change soon. 

Monday, January 18, 2010

Haiti: Vodka and hacksaws

Sixty Minutes (video, 12 mins long); doctors explaining how they are amputating without adequate supplies. Civil War medicine indeed.

Of note: the United States has evacuated 4 patients for treatment. The country of Martinique has reportedly accepted 200. Why this large discrepancy? Is Haiti's and Martinique's shared relationship with France somehow greasing the wheels? Are the patients able to go to Martinique because they are bypassing the congested airport (it's an island as well)? Has the US chosen to focus on on-site treatment and infrastructure rather than evacuation--is that a better long-run strategy? Are there immigration difficulties?

Friday, January 15, 2010


With moderate supplies, we can try to practice low-resource medicine. Without supplies, doctors and nurses don't matter. No real medicine takes place, and a hospital becomes a mere gathering of medical personnel. Or a morgue.

* Outdoor amputation with local anesthesia (video).

* Underequipped field hospital whose physicians are doing what little they can (video).

* Logistical nightmare for Doctors Without Borders (article).

No one could have prevented the earthquake, but Haiti was especially vulnerable because of shoddy infrastructure and lack of health services. The historic reasons for this are many and wretched. Tracy Kidder points out that there are 10,000 aid organizations established in Haiti, yet it remains obscenely poor. Educate yourself about Haiti and about Partners in Health's medical efforts there in his unforgettable book Mountains Beyond Mountains.

OF NOTE: Going to Haiti? Need some Creole? As of 1/15/10, Transparent Language is offering their "Byki Haitian Creole" software for free on iTunes, as their way of helping. And Pimsleur offers its first ten lessons of Haitian Creole free as well.

Tuesday, January 12, 2010

Nearsighted and farsighted

The price we pay for want of eyeglasses is steep: $269 billion a year. That number, published in a 2009 WHO-affiliated study, is an estimate of worldwide lost productivity due to refractory error--a kind of vision problem, like nearsightedness, that glasses can fix. But, though eye exams and eyeglasses don't cost much, they require lens-grinding equipment, an optometrist, and a machine into which to trustingly settle the chin. All of those are in short supply in many countries. Who's tackling cheap vision correction?

Gadgeteers, it turns out, are drawn to eyeglasses just as they are to cookstoves. The holy grail of low-resource eyeglasses are the kind you just hand to a person--he puts them on, adjusts them, and sees. Such glasses exist. The New York Times wrote recently about high-tech eyeglasses that allow untrained wearers set the focus themselves, some using a sliding-lens system and others an injectable liquid. The companies developing this technology, which include AdSpecs in England and Focusspecs and U-Specs in the Netherlands, plan to drive down production costs and send millions of eyeglasses to poor countries, thereby helping many of the 145 million people who have bad vision from uncorrected refractive errors (but not with astigmatism--those people still need optometrists). The website of an organization affiliated with AdSpecs, Centre for Vision in the Developing World, explains how the glasses work; it's well done and worth a visit.

But as a former U-Specs executive pointed out in the Times article, the real cost is not in the nifty glasses themselves, which will be a few dollars or less once economies of scale are in place, but in their distribution. After all, many donated pairs of eyeglasses already make their way to poor countries through organizations like New Eyes for the Needy. That group claims to distribute hundreds of thousands of pairs each year, a number that dwarfs what the gadgeteers have yet accomplished--and demonstrates that powerful built-in networks for distributing glasses already exist. Are all these parties talking to each other?

Similarly, Vision 2020, the cleverly-named partnership between the WHO and the International Agency for the Prevention of Blindness, is tackling all forms of avoidable blindness, with an emphasis on developing better infrastructure rather than passing out post-optometry eyeglasses. As with so many low-resource problems, solutions to preventable blindness are many and partial. The best one may remain to be seen.

Wednesday, January 6, 2010

Speaking to your patient: medical phrasebooks

Pocket guides to help clinicians speak a foreign language to their patients are hard to find for most languages. But there are a few on offer. The trouble with speaking from phrasebooks and dictionaries, of course, is that the person who painstakingly mouths syllables then has to brace for a fluent and incomprehensible reply. So a human translator is invaluable. But I like to make an effort to speak in the language myself,* if only because my patients' laughter at my attempts makes for good medicine.

You can get medical Spanish, French, and Russian resources by Russell K. Dollinger on Amazon, and some come with audiotapes or CDs. There are other Spanish-language resources besides his, but I mention it because it's a nice series and because Dollinger is developing a gadget to allow for more inter-language communication. (Read more about his Interphraser here.)

Swahili book is available to English speakers.

The British Red Cross mails a free copy of a 36-language phrasebook for emergency conversations to British physicians. It can be ordered and downloaded online. I can't wait to print out those PDFs and give Pashto and Turkish and Amharic a try.

A book called Medical Translator contains phrases in languages commonly used in the US, including Spanish, Chinese (they don't specify which on the Amazon page), Italian, French, German, Creole (again, which creole they mean is not specified), Korean, Vietnamese, and others. Unfortunately, it seems only to be available in a German edition.

And here is the mother of all bibliographies for foreign-language medical glossaries, compiled by Jacquelyn Coughlan at SUNY Binghamton.

*I recommend Pimsleur audio programs to get you comfortable wrapping your tongue around foreign syllables.

Sunday, January 3, 2010

First-person accounts from MSF docs in India and Zimbabwe

I'd like to call your attention to three blog entries at the British Medical Journal's website, in which three physicians write about their work in low-resource settings with Médecins Sans Frontières (MSF, a.k.a. Doctors Without Borders).

Joseph Jacob discusses working in Kashmir and Chhattisgarh, India, where he and his colleagues are treating malnutrition, scabies, leprosy, TB, mental health disorders, malaria, and obstetric conditions. They also responded after Cyclone Aila hit India and Bangladesh in July '09.

Caroline Forwood writes about Bihar, where kala azar is endemic. This vicious disease, also known as visceral leishmaniasis, is transmitted by the sandfly, a creature 3 millimeters long that bites. Treatment options for this disease are few, though two new drugs were approved for use in India in the last decade. The MSF docs are using amphotericin B, which is expensive and carries serious side effects but is highly effective and readily available.

Philipp Du Cros gives the reader a look at his job improving or starting tuberculosis treatment programs, and focuses on MSF's efforts in Zimbabwe. What's striking about this and so many other accounts of work in low-resource areas are the descriptions of the distances patients must travel to obtain the most basic care. Add transportation to the list of problems (it includes sanitation, electricity, security, and many more) that are integral to the practice of low-resource medicine.