I hope to gain continued experience working with the local community of Abakalaki, Nigeria, which is still suffering from the repercussions of the Biafran War of the 1960s. I would like to understand methods of providing services with limited resources, implement the skills of triage in terms of resource allocation, establish rapport and a lasting relationship with the local community so as to not only better understand their unique medical needs but to meet their needs with ongoing future interactions. Again, my hope is to continue working with local Nigerian communities with the plan of establishing a training program in the future once I have completed my training. During this elective, I will be performing pediatric assessments and triage for children desiring surgical intervention for their ailments, which include the treatment of hernias, cryptorchidism, and other conditions. I will also be performing procedural sedation and other procedural tasks in line with my scope of practice as an EM physician in training.

According to the World Bank and the United Nations Industrial Development Organization (UNIDO), Nigeria is classified as a lower middle-income country. With the wealth of natural resources, it’s unfortunate to see how the potential wealth of my birth nation does not correlate with its national income. As it relates to healthcare, the Nigerian healthcare system is underdeveloped. Assessment of Nigeria’s shortcomings has been linked to a lack of functional surveillance systems and medical intelligence. From my personal assessment, I believe a significant contribution has been physician brain-drain, which was highlighted by the president of the Nigerian Medical Association in an interview in 2013. This is what inspired me to start traveling back to Nigeria to contribute medically in any capacity that I can.

Dr. Karen Schneider, a Pediatric Emergency Medicine faculty at the Johns Hopkins Children’s Hospital, oversees various global health electives to low resource settings. I was inspired by her continued commitment to pediatric medicine and decided to travel with her to two small villages in Ebonyi State, Nigeria – Ikwo (Abakiliki) and Ishiagu. I am forever grateful to the Johns Hopkins Center for Global Health for the opportunity to become a Paul S. Lietman Global Health Travel Fellow, which provided me the opportunity to participate in the elective.

Upon arrival to Nigeria, I felt an immediate sense of nostalgia for my childhood days in the village of Akwa-Ibom. I started my elective in Ishiagu working in an Adult Medicine Clinic with Dr, Mercel, a Nigerian physician who works in the US but travels annually to provide care to his local village-people. I worked alongside 9 other physicians seeing adult patients, triaging their complaints and providing care to them with what little we had. In two days, I saw over eighty patients on my own. As a whole, we all saw over five hundred. My days in Ishiagu opened my eyes to the true needs of adults in rural Nigeria, which includes ophthalmologic care, gynecologic care and issues related to chronic pain. We were equipped to provide medications for diabetes, hypertension and acute pain, but we are unprepared for the prevailing issues of blurry vision due to cataracts, chronic pain due to repetitive farming and poor body mechanics and vaginitis, among other complaints. I reported these findings to Dr. Mercel to discuss the need for considering a Surgical Eye Clinic in the future and bringing along medications to combat female gynecologic complaints. As it relates to chronic pain, the local villagers would benefit from an allied health provider who is able to provide long-term physical therapy education.

Crowd at the Adult Clinic in Ishiagu, Ebonyi State, Nigeria

After the Adult Clinic in Ishiagu, I traveled to Ikwo, a nearby city to Abakiliki, where I performed pediatric anesthesia for pediatric surgeries for the repair of hernias, hydroceles, undescended testicles and unknown testicular masses. Our pediatric surgeons performed over 150 surgeries, and I performed anesthesia on thirty of those cases. It was humbling to interact with the families who praised us for the care that we provided for their children. It opened up my eyes to the prevalence of these conditions, which I did not appreciate until this trip. Performing these surgeries is critical because without it, these children would be destined to a future of chronic abdominal pain, the possibility of bowel strangulation, which is life threatening and even possible infertility. 

In addition to the pediatric surgeries, I had two patient encounters that changed my life. While in Ikwo, a female in her twenties came to the clinic after a syncopal episode. She was waiting in a private room to see the local physician when she screamed out in pain. I ran to her side to witness her miscarried fetus on the ground; she unfortunately suffered a miscarriage in her first trimester. Her syncopal episode was likely due to an inevitable abortion. I immediately laid her down on the clinic floor and decompressed her uterus to ensure that there were no retained products of conception. I massaged her fundus to ensure that her uterus was appropriately contracting down, and I placed her fetus (with intact amniotic sac) in a blue surgical sheet for her and her husband to take home to bury. I spoke with the local physician who supported my care and thanked me for my immediate attention to the woman. Understanding Nigerian culture, I sympathized with the woman because I know that for many Nigerian women, our worth is tied to our ability to procreate and bear children. Luckily, her husband appeared very supportive and remained by her side as we provided comfort care for her as she was in shock.

Left: Administering medication to a child prior to surgery. Right: Pediatric Surgery case. Patient, Meredith Lu, RN (first assist), Dr. Karen Cartwright, MD (surgeon), Agnes Usoro, MD (anesthesia)

Secondly, in the home that we stayed in Abakiliki, the gait-man approached one of our surgeons regarding pain he had in his right big toe for several months. The surgeon consulted me for advice, as it appeared to be a condition more up my ally as an Emergency Medicine physician. I saw the patient and was immediately concerned with a paronychia. I grabbed supplies and drained the abscess, which was by far the largest abscess that I’ve drained to date. The patient immediately endorsed relief and was able to walk on his toe for the first time in three months. We unfortunately did not have oral antibiotics to provide him to supplement the procedural drainage, but I provided him with several packets of topical bacitracin as well as my email for follow up. He sent me an email two weeks after returning to the US, and extended his gratitude, stating that he continues to do well.

While my group returned to the US after the pediatric surgical trip, I stayed behind and returned to my home state of Akwa-Ibom. I visited two local hospitals, Ibom Specialist Hospital and Uyo Teaching Hospital to discuss how I can become involved. I was welcomed and received with great enthusiasm. My goal was to establish connections and network with local physicians; mission accomplished. I concluded to start a project teaching local healthcare professionals the skills for basic life support and advanced cardiac life support. I plan to perform my first set of classes sometime in the next two years. It will first require me to obtain an educator certification in both BLS and ACLS, which I am working on. Once this project is underway, the next step will be to start other local projects related to emergency medical services and eventually, start working clinically once I have completed by residency and obtained board certification.

Overall, I had an amazing time in Nigeria and achieved my overall goal of establishing relationships with local healthcare providers with hopes of giving back my time by working clinically in Nigeria. Long term, the goal will be to establish more sustainable clinical training programs in Akwa-Ibom that helps to address the brain-drain problem. This trip opened my eyes to some of the real clinical concerns patients are having, which I will work to better address on future trips. I learned so much about myself during my elective, which contributes overall to my growth as a physician, and the grant played a significant role in this journey. Thank you.

Resources:

Welcome, M.O. 2011. The Nigerian healthcare system: Need for integrating adequate medical intelligence and surveillance systems. Journal of Pharmacy and BioAllied Sciences. Oct-Dec; 3(4): 470-478.
Campell, J. 2013. Africa’s brain drain: Nigerian medical doctors. Blog post for the Council on Foreign Relations. Obtained from: https://www.cfr.org/blog/africas-brain-drain-nigerian-medical-doctors