A Report by Oluyombo A Awojobi, Operation Hernia Project Coordinator in Nigeria.
Introduction: The seed of the third front of OPERATION HERNIA, OH, missions to Nigeria was sown in June 2009 when Dr J I Umunna, a rural surgeon of Jasman Hospital, Limited, Udo-Ezihinitte, Imo State, Nigeria, participated in the first Nigerian mission of OH at Awojobi Clinic Eruwa, Oyo State, South West, Nigeria. He made a request to Prof Andrew Kingsnorth, director of OH, for the extension of OH missions to the South East of Nigeria, his home geopolitical zone. Rather than have the mission conducted in his hospital, Dr Umunna co-opted other members of the Imo State branch of the Association of Rural Surgical Practitioners of Nigeria, ARSPON, of which he was the chairman, and they decided on hosting the mission at the government General Hospital, Abor-Mbaise, GHA.
Preparation: Although a site inspection was usually conducted by Andrew, this was not the case this time due to his tight schedule in Cote d’Ivoire. In fact, the mission slated for Eruwa was shifted to the South East. As project coordinator of OH in Nigeria, I visited the GHA on 16th/17th October 2010. This was preceded by exchange of emails that included several pictures of the hospital and its facilities. Thus, a prima facie case for the suitability of the hospital was made. My inspection confirmed this. The hospital was built by the Catholic mission several decades ago before it was taken over by the government. As with other Catholic mission hospitals, this hospital was well laid out on an expanse of land. I recommended that the theatre be upgraded by tiling the floor and providing efficient autoclave and air conditioning system. I was assured the government was enthusiastic about the mission and would carry out the refurbishment quickly. Further preparation for the mission was set in motion with the recruitment of volunteers by OH and getting patients with inguinal hernia. The latter was achieved through the mass media operated by Imo State government. It turned out that many patients had travelled from far and near even from the neighbouring states. By the time the mission started, over 400 patients had been booked.
Reception of the Volunteers: The OH team included Drs Petr Bystricky (from the Czech Republic), Scott Leckman (from the USA), Denis Blazquez (from France) and the leader, Prof Andrew Kingsnorth (from the UK). I received Scott on Friday 25th February 2011 and we lodged at LaSal Hotel close to the Lagos Airport while Denis, Petr and Andrew arrived the following day. The team brought with it one portable Little Sister autoclave, four sets of surgical instruments for hernia repair, lots of gloves and suture materials. Earlier on Saturday morning, I took Scott on a brief tour of Lagos showing him the public park and avenue named after my elder brother, Prof Ayodele Awojobi, a mechanical engineering genius, mathematician and social reformer. We went to the department of mechanical engineering, University of Lagos, Unilag, where he taught and the alma mater of the Awojobis, CMS Grammar School, Lagos ending up at the international airport to await the arrival of the other three. At the Unilag, we observed the growing trend in Nigeria of replacing louvered windows that allowed 100 per cent ventilation with the sliding windows that looked more aesthetic but reduced ventilation by half. We felt this was unbecoming of a citadel of knowledge and relevance to the society in these days of global warming.
The Mission: The team flew into Owerri on Sunday 27th February into the warm reception of our colleagues led by Dr Jerome Afuka, national secretary of ARSPON and secretary of the Imo State branch. However, we were startled by the presence of five fully armed police men who would be our escort for the next six days. We quickly checked into the Mayfair Hotel on the outskirts of Owerri before proceeding on a 35-minute drive to the GHA where we were received by Dr Cosmas O Madu, the medical officer in charge of the hospital and scores of patients waiting for surgery. Andrew proceeded to examine the adult patients for surgery the following day and drew up a list of paediatric and adult patients which he handed over to Cosmas with the hope that work would start in earnest the next day. It was noted, at this point, that there were no proper case notes of the patients, just the list indicating sex, age and type of hernia. By 5.30pm when that first exercise was just being concluded, the security operatives were alerting us that it was time to depart for the hotel. And so, the team could not inspect the theatre facilities before returning to the hotel.
Financial Matters: During the preparatory period, it was decided that OH would be responsible for the internal flight tickets, the hotel accommodation and meals in Lagos and Owerri. Accommodation and meals in Owerri would cost N5000 per day per person. By the third day, Jerome informed the team of the huge expenses the association had incurred to get the mission going: N70 000.00 (?1 = N250.00) to obtain police protection, the hotel bill with one room reserved for the police who were fed, fuelling of the government bus allocated to the team and feeding the driver, allowances to the hospital staff, who were on industrial strike action, before agreeing to help with the mission. The hotel facilities were good enough but pretty expensive ? N11 000.00 per night with complementary breakfast. As a consequence of this expose, Andrew decided to double the commitment of the team while I waived the expenditure for the Lagos end of the trip amounting to N220 000.00. I advised Jerome to present any deficit incurred by the local branch to the national body for consideration since the Imo State branch had contributed more than any branch or individual to the sustenance of ARSPON. The doctors in the public service of Imo State were on strike before the mission started and a lot of pressure and persuasion was needed to get the striking doctors allow the mission to go on in the public GHA.
The Actions: Day 1, Monday 28th February Work started very late at about 10.00am. The team arrived GHA well before key members of the host team due to the fact that most of them resided in neighbouring towns about an hour and a half drive from the hospital. Jerome who lives a stone’s throw from GHA did not have the administrative power to influence the goings-on. By the time the mission was in full swing, Andrew realised many of the patients he had operated on were not on the list he prepared the previous day!! The hospital staff had hijacked the list before the arrival of Cosmas. The team left the hospital by 5.30pm having operated on 13 patients that included 6 children. At the hotel, Andrew handed to me the donations (?5 160.00) sent by Dr Ramon Vilallonga-Puy of Spain and Mr John Pickering of the UK in aid of the construction of a hernia centre and solar-powered lighting system respectively at Eruwa.
Day 2, Tuesday 1st March. The day started for me at 12.05am with a text message from my teacher, mentor and benefactor, Prof O O Ajayi, CON and it read: ?At 60 years of age today, you have carved for yourself an indomitable reputation for hard work and indisputable integrity and transparency in public service with love, charity, care and compassion. You are frequently misunderstood, not out of ignorance or intellectual barrenness, but because you outmatch all by a vision many cannot understand. The solution is in your hands. Yombo, many happy returns as you build on a God-given talent for an enduring legacy on earth and for His eternal glory in Heaven. May God continue to keep you and bless your family as promised for those who serve Him. Amen. Happy birthday to a loyal, generous, affectionate brother. Many Happy Returns. Jide Ajayi. At day break, I informed the team and my colleagues in ARSPON of that milestone and they all congratulated me and expressed their gratitude for the roles I had played in organizing the mission. Things worked out better on day 2 with some sanity restored to the list prepared by ARSPON members and the theatre system functioning well. The State Commissioner of Health, Dr F Ekwem, visited and was met by Drs Umunna, Madu and Andrew. The commissioner briefed the audience of the efforts of government in health care delivery in the state and thanked the OH team for coming despite the security situation. He promised a better reception the next time. Andrew, while reciprocating the complimentary remarks of the commissioner, observed that a three-year old maternity wing of the hospital built by the present administration with World Bank assistance was already depreciating due to disuse. I presented to the commissioner a set of books and booklets that included the third edition of Davey’s Companion to Surgery in Africa which I co-edited and published, the programme booklets of ARSPON 2008, 2009 and 2010, SURGEON IN THE BUSH by Dr Umunna and my other publications. I attached a copy of a paper I proposed to read if there was a formal reception. (Appendix 1) An hour later, I sent pictures I took on the occasion by email to his public relations officer.
Discussion with Dr Omunna
Day 3, Wednesday 2nd March Just as the mission was gathering momentum, it was observed that the only heavy duty generator (60kVA) was malfunctioning and autoclaving of instruments was unusually long. The technician informed us the generator was old and was recently repaired. The theatre staff was bypassing the autoclaving by soaking the instruments in antiseptic lotion.
Together with Jerome and some of the patients, I organized that a mobile generator be rented for days 4 and 5 if things did not improve. The technician was brought into the picture. However, I observed that soon after our discussion, the performance of the generator improved such that work continued smoothly. Meanwhile, Andrew had opened up another makeshift theatre with two operating tables in the near-abandoned maternity wing so that he and Scott could deal with small hernias while Petr and Denis tackled the children and giant hernias in the first theatre. At about 5.00pm, I was informed that the nurse anaesthetist would not proceed with the children because there was no more intravenous infusion. I took over the situation, requesting Jerome to administer intramuscular ketamine while I performed herniotomy on four children assisted by a colleague. By now, several colleagues had assisted and been taught tension-free mesh repair of inguinal hernia by members of the team.
Day 4, Thursday 3rd March The day started well. The generator (7.5kVA) had been brought by the owner and placed at the appropriate place near the theatre for use if the big generator malfunctioned. It was to power the portable autoclave exclusively and not for the theatre section of the hospital since it was not powerful to do that. I paid the owner a deposit of N5 000.00. At 11.30am, Andrew, Jerome and I set out to visit Dr Umunna at his base. But before leaving, I reminded the theatre technician in charge of the autoclave and the owner of the generator of my directive as to the use of the generator.
At Jasman Hospital, Udo-Ezinihitte, we were cordially received by Dr and Mrs Umunna and the members of staff. A mini ward round was conducted on patients who had had modified radical mastectomy for carcinoma because there was no facility for radiotherapy in the South East, prostatectomy, hysterectomy, suprapubic cystostomy for impassable urethral stricture etc. We saw the conference room used for ARSPON 2009 and the adjoining cafeteria. Andrew was presented with an autographed copy of Dr Umunna’s book, SURGEON IN THE BUSH. I promised I would send him pictures of a simple operative procedure to treat the patient with urethral stricture. This I did some days later when I operated on a man with stricture.When we returned about three hours later, the situation was chaotic due to malfunction of the big generator and failure to use the rented generator. I was told the government technician had insisted that the rented generator be connected to the theatre. I was so furious I carried the autoclave from the theatre to be placed under a tree with the generator near it. In 6 minutes, surgical materials were being autoclaved and the mission continued in full swing. I did not seek for the technician since he had, by his action, identified himself as a saboteur. One of the patients, an elderly man who had worked in the hospital, assisted with operating the autoclave. He had his hernia repaired the following day. The team left the hospital at 6.30pm because our escort and we were getting more relaxed psychologically. I paid the owner of the generator the balance of N5 000.00.
During one of the evenings at the hotel, we were told about the spate of kidnappings in the state that included the former commissioner of health and one of our colleagues. Heavy ransoms were paid to secure their release. This explained the heavy security presence around our foreign guests. On this basis, Petr, who was billed to stay an additional week, decided to come with me to Eruwa where security issues were not so serious. Discussions were laced with the political happenings in the state and the country.
Day 5, Friday 4th March Scott was scheduled to return to the USA on this day and so, I accompanied him back to Lagos to await the arrival of Andrew, Denis and Petr the following day. Before setting out, my colleagues presented me with the traditional Igbo attire to mark my birthday and in gratitude for a mission accomplished. The generator was still available in the hospital for use. Jerome paid the rent for that day.
Day 6, Saturday 5th March I met Andrew, Denis and Petr at the local wing of the airport and moved on to the international wing where I bid farewell to Andrew and Denis while Petr came with me to Eruwa. At the end of the mission, 120 patients were operated on leaving over 300 to be taken care of by the local team at affordable rates in their respective hospitals.
The team left behind the autoclave, the four sets of instruments and the unused gloves and sutures. I had loaned the mission two diathermy machines and an autoclave meant for Eruwa centre. I hope to repossess them in time for the next mission in November 2011 during the joint conference of the International Federation of Rural Surgery and ARSPON. A 12-year old indigent boy had not had his hernia repaired since 2008 when the government launched a free-health programme. I handed him over to Jerome to fix his hernia on my bill. AT ERUWA Scores of patients had been waiting for me and throughout the next six days it was work from dawn to dusk starting with an obstructed inguinal hernia on Sunday 6th March. Petr and I performed 35 major surgeries in five days which included excision of giant tumors, torsion of ovarian cyst, drainage of 8 litres of pus from the peritoneal cavity, sequestrectomy of neglected chronic osteomyelitis, thyroidectomy, prostatectomy and some hernias which Petr fixed with the Indian mosquito mesh that was used exclusively at GHA.
Petr left Eruwa for his home country on Friday 11th March on a three-hour trip to Lagos by a chartered taxi. He reported safe arrival at home like other members of the team.
Comments: As noted in my proposed speech, I thought the Imo State Government was performing better than the others as far as health care delivery was concerned. But, this was not so as shown by the attitude and conduct of the hospital staff and the ongoing strike action in the health sector. Overall, the hospital staff did well but at great expense to ARSPON. The decision of my colleagues in ARSPON, Imo State branch, to choose the GHA was good. It was an opportunity to improve the image of the government and ARSPON thereby disabusing the minds of the populace who felt private doctors were exploiting them and so became targets for kidnapping. Although the patients were not charged any fee for the exercise, I was told by my colleagues that some still felt the doctors had collected large sums of money from our guests. I spoke to the patients on the rationale of the mission, the logistics and the expenses incurred by everybody involved in the exercises. I usually ended my talk with ‘If you were in my shoes, what would you do’. Their responses and comments indicated that out people would feel more at ease if they were carried along in the decision-making and execution processes.
In a five-day mission, 120 inguinal hernias were repaired and over 300 patients were still waiting. There are about five teaching/tertiary hospitals in that region. This shows their low level of impact on health care delivery in the region. The absence of proper documentation of the patients will make future review of the cases impossible. This is not good for the science of surgery.
Although, we knew of the security situation in the South East as in many parts of Nigeria, we (OH team and I) did not realize it was really that bad that a commissioner and a colleague had recently been kidnapped. However, we would recollect that Chief Bola Ige, the Attorney-General of Nigeria was assassinated in his room in Ibadan in the South West while being guarded by ten armed policemen some years ago and no one had been charged for it, then any crime could be committed with impunity in this country. So, it was understandable why our colleagues took such extraordinary precautions to ensure the safety of our guests. I must thank them most sincerely for still keeping faith with the Hippocratic Oath we swore to at induction into the profession despite the hostile situation they practice in. The administrative lapses observed were beyond their control and I quite appreciated the milieu in which Dr Madu was performing his onerous duty having been a public employee in the past. It was all praises for Andrew and his team for braving the odds in the spirit of Medicins sans frontier. However, it would take a long time before another mission is contemplated.
I want to thank the members of staff of Awojobi Clinic Eruwa for holding fort and Dr S Ogunsina who came in from Ibadan to perform some emergency operations and his usual Saturday round of hernia repairs. This has been the third side of the countless sides of a coin that is OPERATION HERNIA in Nigeria.