Learning about health care in Africa: A physician’s experience in Lagos, Nigeria

Lagos students in their uniforms, heading to school.

Africa has long been a destination for medical and religious missions. As far back as the mid-1400s, Britain and other European countries sent missionary teams into the interior of what was at that time referred to as “The Dark Continent.” In later years, medical teams worked to understand the diseases that were killing not only the native inhabitants of this region, but also the members of various exploratory and other expeditions.

In the late 1800s, compassion was not always the driving force behind humankind’s desire to understand and treat sleeping sickness, malaria, and yellow fever. The value of Africa’s natural resources and the developing concept of social Darwinism were likely the most compelling reasons for understanding, and eventually curing, these deadly diseases.1,2

In spite of the imperialistic intent of some past missions to Africa, I felt compelled to join the long roll of medical missionaries who went to Africa for the right reasons.

Expectations

Having read of David Livingstone, pioneering medical missionary from Scotland, and with visions of Noble Prize Laureate Robert Koch, MD, in my head, the mission team from Trinity United Methodist Church of Gainesville, FL, arrived in Lagos, Nigeria, on July 3, 2010, with a broad range of responsibilities. The medical team was to staff a medical clinic at the West African Theological Seminary (WATS). I had come prepared to look for and diagnose Madura foot, leishmaniasis, sleeping sickness, malaria, and even dengue fever. The clinic provided care for a diverse group—from PhD candidates who were in school at the seminary and their family members, to local people who came from many socioeconomic levels. Walking to the clinic on the first day, I noticed the cleanliness of the children and their clothes, and the meticulous manner in which mothers cleaned their homes—and how that contrasted so sharply with the overall sanitation of the neighborhood. Young women walked to work or school in polished high-heeled shoes dodging water and mud puddles all the way. Cars and motorcycles navigated potholed roads to avoid deep puddles and open ditches on either side of the road. People urinated and defecated in public with abandon.

The team arrived at the clinic and followed the directions of Florence, the matron who was organizing the operation. Florence told me that “the drums had been sounding” for some time before our arrival, and she expected we would have busy clinics. She was correct.

Reality

Expecting to see unique tropical diseases that I had only read about, I set out to see my first patient. It was then that I began to realize that I was about to begin practicing the true art of medicine. I have to thank my medical school professors, my residency training, and my 25 years of medical practice for giving me a strong understanding and appreciation for physical diagnosis. At first, I believed that my medical impressions would comprise the diagnosis and that there would be little opportunity for confirmatory testing. To a certain extent that was true, but I quickly learned that sophisticated laboratory testing and diagnostics were close at hand and reasonably priced. All health care services (provided on a cash-only basis) seemed very responsive to the patients’ needs.

Entrance to Dr. Ekhakite's private clinic and hospital.

Entrance to Dr. Ekhakite's private clinic and hospital.

Throughout my daily work, I kept waiting to evaluate a patient with an unusual disease process, but instead, I found myself treating every general medical condition that American physicians treat today. Over the course of my eight days in clinic, the team saw patients from three weeks to 85 years of age, performed routine physicals and well-baby visits, and reassured the worried-well. Multiple patients were experiencing peri- and postmenopausal symptoms. I counseled patients on family planning issues and explained the ovulatory cycle repeatedly for young married couples. Concerns about sexual health were common, and counseling again played the biggest role in these situations. Prostatitis, or BPH, was common and Hytrin was a commonly prescribed drug. For these patients, prostate levels were easily obtained in local laboratories.

Hypertension was ubiquitous, and, in many cases, the patient knew about it but had little interest in staying on medications. I came to recognize as normal that most of the patients had what appeared to be elevated diastolic blood pressure. This seems to be in keeping with data about African Americans in the U.S.3
Adult-onset diabetes was another common but growing diagnosis. The carbohydrate-rich, low-protein diets and overweight-to-obese Nigerians prompted many sessions on the merits of diet and exercise in order to control weight, blood sugars, and blood pressure. The challenge, the team discovered, was convincing patients to take the medications rather than use the herbal “remedies” prescribed by the local shaman. Routine exercise is not a traditional practice for the average hard-working Nigerian.

Over the course of the trip, the team encountered some interesting pathology. I found two patients with aortic stenosis, both having a mid-systolic, II/VI systolic ejection murmur confirmed on an echocardiogram. Two potential prolactinoma patients were evaluated and diagnosed. Both women were postpartum and had not breast-fed for 18 months but were still lactating and could not conceive. Laboratory testing, bromocriptine, and referral were my only recourse, but consultation with Moses Ekhakite, MD, informed me that prolactinomas were quite common.

I treated foreign bodies in ear canals and found several children with acute otitis media. One child had chronic otitis with a small anterior perforation that had started draining. She was started on Cortisporin otic suspension and Augmentin elixir. The patient was referred to an otolaryngologist for follow-up and repair.
Despite my best efforts, I was unable to find and treat a patient for malaria, typhoid, or any other tropical disease. Many patients are treated for malaria simply based on symptoms and not on laboratory documentation. This unrestrained treatment protocol and the over-the-counter availability of Chloroquine probably account for malaria’s near-universal resistance to the drug in Africa. Overuse of malaria prophylaxis has added to the progressive resistance from the most fatal malarial species, falciparum. Europeans do not recommend prophylaxis, particularly for travel in urban areas, because the risk for contracting the disease is low.4

Near the middle of my stay, I finally came across a patient who potentially had cutaneous leishmaniasis (CL). Four years earlier, she had been treated for an anterior tibial compartment syndrome with fasciotomy and drainage. The wound healed slowly but never completely resolved. The girl stated that it started from a bug or fly bite on the back of her calf. History revealed that she had been treating it with gentian violet (purple staining) and penicillin powder with no success. Her wound was classic in appearance for CL, with a whitish covering, fine granulation tissue underneath, and rough patchy edges. There were several options available for treatment, including Amphotericin-B, Diflucan, and Paromomycin. The first trial was for Diflucan, given its safety and availability in the country. She was also referred to the state hospital for biopsy and a possible skin graft.

During our off hours, I made a trip to visit the local Sikenu Hospital, owned and operated by the physician who staffed the WATS clinic one day a week. A graduate of the Nigerian University of Medicine, Dr. Ekhakite was very knowledgeable and well-trained. He was kind enough to show us around his facility, and I was impressed by the volume and breadth of his general medical practice. He had a small lab to test for malaria and typhoid (white out test), and he performed 2-D ultrasounds with some skill. In his operating room, he performed appendectomies, hernia repairs, cholecystectomies, cesarean sections, prostatectomies, and minor procedures. Dr. Ekhakite’s recovery room was adequate, and his four-bed inpatient ward served the community well. We referred a five-year-old child to the hospital who, for two days, had been suffering from diarrhea, nausea, and vomiting with moderate dehydration. She was evaluated and treated by Dr. Ekhakite with IV fluids, antiemetics, and bowel rest. Typhoid testing was negative but she was treated for 24 hours with IV antibiotic therapy. Follow-up visits revealed her gradual improvement.

The highlight and low point of my physical diagnostic experience came when I evaluated a professor teaching at the seminary. She was of Northern European descent, blue-eyed, blonde, and fair-skinned. She denied any family history of tremors, although she had been out of the country for many years. She complained of a mild tremor in her hands and tiredness. Further questioning revealed that she had lost her zest for her mission. She had noted some difficulty sleeping, swallowing, and recent constipation, and her gait had slowed. A physical exam revealed bilateral resting hand tremors with subtle pill rolling that improved with movement. She had a resting head bobbing or tremor. Her tongue had a mild tremor, and her reflexes were asymmetric but present. Finger to nose normal, gait slowed but improved with walking. Upper extremity range of motion demonstrated classic right greater than left cogwheel rigidity.

Why was diagnosing a patient with Parkinson’s disease the highlight of my experience? Several years ago, I, too, was diagnosed with Parkinson’s. As a result, I was in a position to provide the patient with information and insight. I spent time discussing my clinical impression with her, the various treatments available, and what she may expect in the future. We discussed the pathophysiology of the disease and decided on a trial of Sinemet 25/100. I saw her five days later and she was already feeling better. Her mood, gait, and tremor had improved. I did convince her to seek a second opinion from a neurologist back in her hometown in the U.S., which she arranged.

The most logistically difficult case I encountered was a patient whom Dr. Ekhakite referred to me. The patient was a 36-year-old female, G3-P2-A0, 29-week gravid with biopsy-proven metastatic lymphoepithelioma in the left neck. She was a non-smoker and non-drinker and was asymptomatic except for a 3-4 cm swelling in the left tail of the parotid, post-auricular area. A computed tomography (CT) scan revealed only the left neck masses with no other nodes or neck masses present. A chest CT was negative, and a biopsy had been reviewed both in Nigeria and in Britain, with findings consistent with Epstein-Barr virus and lymphoepithelioma. Her case was complicated by her pregnancy. Dr. Ekhakite suggested steroids to accelerate the child’s surfactant pulmonary maturation, with the aim of delivery in several weeks followed by definitive treatment for the woman. After further consultation, it was recommended that she undergo a biopsy of her nasopharynx, base of tongue, and a needle biopsy of left parotid. She was also scheduled for high-resolution CT of her head and neck, with attention to the nasopharynx with bone windows. She was referred to the U.S. for treatment. A letter to the U.S. consulate for an emergency medical visa was submitted; however, due to embassy issues, costs, and expedience, the patient elected to seek treatment in India instead.

Dr. Ekhakite's recovery room

Dr. Ekhakite's recovery room


Final impressions

I had been conditioned, over the years, to believe that Africa was a continent where death and disease lurked behind every tree and within every flying insect. The reality is quite different. I found few to no unusual diseases in the urban areas of African cities. Lagos, a city of 18 million, has an integrated and competent health care delivery system. Pharmacies were adequately stocked with state-of-the-art medicines. Hospitals—although not elaborately designed when compared to such facilities in the U.S—are privately owned and staffed by trained and capable physicians and nurses who have access to reliable medical laboratories. None of these facilities would likely meet The Joint Commission’s accreditation standards, but all provided excellent care with compassion and had good outcomes overall.

Surprisingly, Nigeria is beginning to experience growth among those chronic disease processes commonly associated with Western societies. Additionally, family planning is becoming a bigger part of the national dialogue, as men now seek vasectomies. This is a big cultural and emotional step for many men in Nigeria and other African countries, where traditionally a man’s societal success has often been measured based on the number of children he has fathered. All other modern Western methods of birth control are available in Lagos, and while I was there, women were beginning to use them. Interestingly, the women, men, and medical community accepted expanding birth control measures and family planning methods but uniformly opposed abortion as a birth control method. This evolving acceptance is still being met with resistance in other countries on the continent.5

Dr. Ekhakite's operating room

Dr. Ekhakite's operating room

All of the children were vaccinated and well-cared for, in spite of the levels of poverty and poor sanitation that I witnessed during my visit.

Most children attended school and spoke English as well as their native tribal dialect. Education is a priority in the society. Many people were pursuing master and doctorate degrees. Some children would get up at 5:00 am to work and make money to afford school, and then go back to work after school to earn money to eat. Everyone worked because there is little to no social welfare system. Markets where every conceivable service or need was sold would go for miles along the roadside as self-motivated, personally responsible people cared for themselves and their families. No one went hungry. With the collective work ethic exhibited by the population, it is easy to understand why they want to come to the U.S. They would succeed here.

I do not want to give the impression that Nigeria is a perfect place. No, it has its problems, including massive government corruption with theft of billions and payoffs to the local police and government officials, which are as routine as buying a Starbucks coffee in the U.S.6 Corruption is just part of doing business there, and it explains why the roads and the sanitation systems are dysfunctional. The judicial system is now beginning to investigate and prosecute officials for this behavior, and local governors are trying to provide better infrastructure using the courts to prosecute those individuals who fail to do their jobs. Nigeria has the potential to become an effective economic and medical leader in Africa if the country’s leadership chooses to allow it to do so. The people are motivated, educated, and capable. I learned a lot from my experience there, and I recommend it to all who have ever wanted to give back in this fashion.

 


References

  1. Smith LN, Parente ST. America’s Healthcare: Through Ignorance, Bigotry, Poverty, and Politics to America’s Uninsured: Medicine’s Long Journey. Stanford, CA: Stanford University Hoover Institution (under review for publication).
  2. Watts S. Epidemics and History: Disease, Power and Imperialism. New Haven, CT: Yale University Press; 1997:256.
  3. Johnson TO. Arterial blood pressure and hypertension in an urban African population sample. Br J Prev Soc Med. 1971;Feb 25(1):26-33.
  4. Freedman DO. Malaria prevention in short term travelers. N Engl J Med. 2010;359(6):603-612.
  5. Africa’s population: Miracle or malthus? The Economist. Available at: http://www.economist.com/node/21541834. Accessed January 3, 2012.
  6. Groping forward: Nigeria’s new government: One and a half cheers for the economy. None for security. The Economist. Available at: http://www.economist.com/node/21538207. Accessed November 28, 2011.

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