Interview with Dr. Joan Okafor-Sea
ADEZE OJUKWU
New Jersey, USA
Sunday, April 4, 2004
Dr. ( Mrs.) Joan Okafor-Sea is an accomplished medical doctor with little or no time for frivolities. She granted this interview after much scheduling and rescheduling, due to her very busy profile. With over 20 years experience in medical practice, the American-trained obstetrician cum gynecologist has been an advocate for safe motherhood. In this two-hour interview with ADEZE OJUKWU, in the United States of America (USA), which was frequently interrupted by several telephone calls, Dr Okafor-Sea spoke on the need for improved maternal care in Nigeria, as well as, other critical health issues. Excerpts:
 Dr. Joan Okafor-Sea |
Q: Let us start with your background?
A: I am the eight of ten children of the Okafor-Ogbaji family in Ndi-Akaemeuno Arondizogu in Imo state. I am an American-trained obstetrician/gynecologist. I have been in private practice for the past 20 years in New Jersey, United States of America (USA), where I live with my husband and children.
Q: How did you find yourself in medicine, and in particular gynecology?
A: By default, one can say. When I left Nigeria for the United States, I intended to study pharmacy. My elder brother, Monsignor (Prof) Festus Okafor, who sponsored my trip, gave me a piece of advice. He said: “With your brains and personality, I do not think you can stay behind the counter all day long." But then I also had my fears. I came here on November 5, 1971 and at that time it was very difficult to get admission into a medical school. At that time getting admission into medical school in the US was so difficult, that a lot of students had to change their majors out of frustration after years hard work. I had my reservations. I was afraid that I could end up with people that could not get in. But as God would it, I got the coveted admission in to med school the first time I applied.
Q That was great. But what was it like in medical school?
A It was competitive. You are in class with the top bright students in the class. I was admitted along with another five Nigerian men. I was the only female Nigerian in the class at the time. Actually looking back, there were no Nigerian females in Howard, University College of Medicine, Washington, DC at that time. The program was tight, so I had to work only during summer months. The American system of education makes it easy for students to work and go to school because of the way the structure is. For foreign students, it was a little different. You must be a full time student, in order to maintain the F-l status which is a minimum of 15 credit hours, which translates to about 4 or 5 courses per semester.
Q Why did you stay on after your studies?
A I came in with an F-l visa with an intention to go back to Nigeria as soon as I am done with my education. But the idea changed when I got married to Dr Julius Asokwu-Sea of Ifite-Dunu of Anambra state. Together we have three sons all pursuing various undergraduate and graduate degrees in universities here in the US. Now back to why I specialized in gynecology. First, I went into this field, because of the high maternal death rate in Nigeria. I felt that if I could save one woman from dying during childbirth, it would be a pay back for my elder sister that died during childbirth. Her death was a colossal loss to the entire family and me. She kind of raised me and later died after three days of childbirth. The baby died in her womb and the medical team put the cause of her death as cardiac arrest. It was therefore a personal vendetta, so to speak, because I determined by God’s grace that any pregnant woman that came under my supervision would come out alive.
Q What are your views on the nation’s health system?
A I have not really practiced medicine in Nigeria, but the low life expectancy age currently put at about 51 speaks volume of our country’s commitment to health and social services. That is one aspect of it. For us here, I mean practicing doctors, there has been an increasing demand for us to pool our resources together in order to help the much we can. One way of doing that is through sending supplies and medicines relatives, friends and organizations. This effort may be small. But of course, if you take 1000 small acts, they will help. This is because when you send money for the purchase of medications, the funds may be diverted to other needs due to the high level of poverty. With reported increases in cases of diabetes, heart-related disease and other chronic disorders, the need to receive regular medications cannot be over emphasized. We also harp on the need for pregnant women to register for ante-natal care early enough, so that doctors can pick up any complication early enough.
Q What about the issue of patient – doctor relationship?
A Thank you very much. This is an area that must be tackled. What you find in Nigeria is a large number of uninformed patient populations. The doctors willingly keep their patients uninformed. It is not right. An educated patient is more likely to be co-operative with the doctor’s advice. As a physician, you may not succeed, if you do not educate patients on their conditions. Patients need to know these basic facts:
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The illness;
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The complications that may arise, if medications are not taken;
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The name of their drugs and their functions and
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The risks if instructions are ignored.
In the US there is a lot of health education in schools, hospitals and in the media. Today there is a focus on obesity as a major preventable cause of death. It used to be cigarette smoking. And there are a lot of campaigns through radio, television and newspapers for adoption of healthier meals with reduction in consumption of high-cholesterol meals. The health department has also started a massive promotion of weight reduction programs. The issue in Nigeria is somewhat different because of poverty, changing lifestyles and other issues. I recall that when I was growing up, you had government hospitals, which offered free or subsidized treatments to people. Consider the fate of the poor, which represents a huge population. A woman who cannot afford to put food on the table for the family may not be able to also afford to pay for health care services.
Q How do we resolve this crisis?
A For a start, the nation’s health care has to be prioritized. There has to be subsidized government owned health facilities that can take care of the poor and needy. This is the situation in the US. The medical field has a tremendous diversity, which takes care of the diverse population and needs. There are the super-specialized centers such as the cancer treatment centers, infertility centers and several others around the country. But within this mix, there are family health centers for the poor. These health facilities are well equipped and run by certified medical personnel in order to protect the health of the entire population. Their care is not reduced because government pays their medical bills. Infact these patients get better care in the long run because they receive optimal care. I want to stress the issue of health education. Look at the problem of HIV/AIDS and other sexually transmitted diseases (STDs). As much as the US has devoted resources and funds to massive public campaigns on these transmissible diseases, you still have STDs in the country. So you can imagine a country that does not devote adequate funding for public health campaigns.
Q Is that the major reason for the spread of the epidemic and other STDs?
A There are several causes including crude medical practices, transmission of infected blood, mother-to-child transmission and sexual transmission. Unfortunately we still have men messing up with young girls. Casual sex has to stop both for the old and young. If you have to engage in such sexual activities, often categorized as casual sex, then it is advisable to use condom.
Q Some religious groups frown at the use of condoms?
A I know you are referring to the Catholic church .I am a catholic and what the church preaches is abstinence and marital faithfulness. The church forbids you to have sex before wedding. So if all faithfuls adhere to this practice abstinence some of the high rate of this pandemic may be reduced. At the same time, if all married couples were both monogamous in sexual activities, it would help.
Q Some denominations also discourage artificial contraceptives.
A Yes you also have the natural methods such as the rhythm method which works well with women that have regular menstrual cycles. Otherwise there are a number of contraceptives now available such as tuba legation, commonly called tying of the womb, IUD, pills and the patch which is the latest and I am not sure that it is readily available in the Nigerian market.
Q How does the patch work?
A The patch is under five years. The Ortho Mcneill drug company developed it specifically for contraception. The full name is Ortho-Evra patch and it can be placed on any area of the body-meaning the skin- apart from the heart or chest region. It operates the same principle as the 21-day pill. But the pill is oral while the patch is transdermal. For instance you place the patch on a Sunday and replace it with a new one the next Sunday. You do this for three consecutive Sundays and then you have a patch-free week at which time menses occur.
Q How effective is it?
A It is quite effective. It has been very good for women who are very busy or who forget to take their pills.
Q Any side effects?
A Sure. It has the same side effects as the pill. They include headache, nausea, break-through bleeding or spotting-in-between as well as weight gain of not more than 5 pound. If you gain beyond 5 pounds, then your physical activity is not commiserate with your eating habits. It may induce a craving for wrong foods. But then one has to beat that. Anyway the patient has to allow for 3 months to enable the body to adjust to the drug functioning prior to addressing tolerability.
Q Again let us go back to the issue of dieting and exercise.
A These play a significant role in maintaining good health. I personally advocate regular exercise such as a 30-minute power walk, or fast-pace walk, 4 or 5 times a week. This is very important because physical exercise improves the body’s cardio-vascular fitness. For instance when you are running the heart rate goes up and this aids the heart’s functions. Every time you undertake an aerobic exercise your breathing is quickened and perspiration ensues. You can also use the treadmill but one has to start with a slow walk-in speed before advancing over time. These are all geared towards preparing the heart for emergencies to put it simply. If you exercise the energy level is higher. As one gets older the bone thins. By exercising with some weight for example a dump-bell, the bone strength is increased and with that when one falls, the bone will not easily break.
Q Does it have anything to do with our food culture in Nigeria?
A Our food is not really, that bad. Americans use vegetable oil with reduced cholesterol. We used to eat balanced meals. We should go back to the way our fathers and mothers used to eat and cook such as steaming, roasting and boiling. Today frying is now the preferred method of preparing food. We now have fried rice, fried yam and fried plantain. I remember that in those days, mothers use to force children to eat vegetables. We use to take a lot of fruits. Now the consumption of fruits and vegetables has declined. In extreme cases some farmers are forced to sell their produce to augment their family income.
Q In our society being fat is generally viewed as an indication of great health and wealth.
A Obesity is not ideal. That was in those days. That view is no longer tenable. Any person beyond his teenage years and is still slim is a picture of good health. This is because your metabolic rate reduces with time. Unless you maintain a regular fitness program, majority of people are bound to gain weight. This can be controlled largely through eating well and working. Actually those who are aged and are slim should be our role models. Women in particular tend to gain weight with childbearing and it takes a lot of efforts to reduce this weight especially with successive pregnancies and lactation.
Q That brings us to the issue of infertility and tendency to seek at all costs.
A Like I said I have never really practised in Nigeria but I have noticed from some of trips to Nigeria and those who come for medical treatment that there is a tendency to abuse infertility medications especially CLOMID. Some patients buy it over the counter without a doctor’s prescription. And this is wrong. There is an indication for clomid as part of infertility treatment. I have seen a number of women in the US who were getting clomid from their relatives and friends in Nigeria. And in some cases this has resulted in very bad complications such as irreparable damage to the uterus, fallopian tubes and the ovaries.
Q What exactly is the indication for clomid?
A The only indication for the use of clomid in infertility is in a syndrome medically known as Poly-Cystic-Ovarian (PCO) syndrome. This comprises infertility, obesity and hirsutism. One of the indications for clomid is in a condition when a woman does not ovulate. The conditions can be summed up as an ovulation, amnorrhea, hirsute and obesity. Any woman that falls into this category may be a candidate for clomid but with a doctor’s prescription. The situation is pathetic the medication can be cancerous. Just recently, one came into my office with a large tumor demanding for this medication. I had to explain that this particular drug could cause ovarian rupture. More so a number of tests were needed to ascertain whether the tumor was a benign tumor, that is fibroid or ovarian tumor.
Q You just mentioned fibroid and it seems to be fairly common. Why is it so?
A Fibroid uterus is the most common benign tumor in women of African origin. About 40 to 50 percent are likely to develop fibroid before menopause whether you ever had a baby or not. The cause is largely unknown so there is no medical treatment to shrink it. Only surgery can be used. But that does not mean people should begin to ask for surgery. A lot depends on the doctor’s examinations and recommendations. This is because fibroid is not always the cause of infertility depending on the size and the location of the tumor. The management of fibroid tumor is always conservative-hands off. In most cases you should leave it alone. A pelvic examination will usually detect it. In morbidly obese patient obese patient you do an ultra-sound. You do not have to remove unless it is symptomatic. If it is not causing pain or problems then you simply leave it alone. Some pressure symptoms include pressing on the bladder, urinary frequency, back aches arising from posterior wall fibroid, which may press on the backbone. It can cause menstrual irregularities such as heavy menses, bleeding-in-between, cramping, passing blood clots.
A Now let us go back to Nigeria’s ailing health sector. Can you please proffer solutions?
Q A lot depends on the government. Health care must be prioritized and this should involve building hospitals or upgrading old facilities as well as increased funding for medical training, research and public health education. Though there is a tendency for the rich to travel abroad for medical check-ups. But there are certain conditions that must be stabilized by the local hospitals before such privileged patients can be flown out. We are aware that certain health conditions afflict both the rich and the poor. So every community should be equipped to manage emergencies before such patients are referred to tertiary health institutions either in the country or abroad for those that can afford the costs.
I wish to stress this point-Nigeria has a lot of brilliant doctors but the operating environment is not favorable. Medical practice thrives on funding. You need to fund teaching hospitals, purchase medical equipment many of which are imported, as well as drugs and other medical supplies. If Nigerian-trained doctors are given the equipment and right conditions, they will perform excellently. We have a lot of Nigerian-trained doctors doing very well abroad and occupying top positions in US, Britain, Saudi Arabia and other countries. The medical schools are very good but a lot depends on the working environment.
Q Now as a person what can you do as a way of helping the sector?
A Really I would like to set up a family maternity back home in honor of my late sister that died during childbirth. But it will be capital intensive.
Q Doc, I wish you the best in this project. You are a very busy working mother what is your schedule.
A I operate a 16 to 18 hour working schedule except for Sundays. My work revolves around my office, hospitals, operating rooms and delivery rooms. Let me explain what I mean because private practice in the US is different from what is obtainable in Nigeria. The Total Women Health Care, is a clinic which, I established about 20 years ago. I see patients there but I schedule them for deliveries or operations in government hospitals. In America you cannot really own a hospital. It is quite expensive. So those of us in private practice are allowed to take privileges in several hospitals after providing all the requirements and credentials.
Q What does this involve?
A For instance if my patient has an emergency, I can refer her to the hospital where I have privileges such as operating, admission, or delivery privileges. In any case, I should be reached easily and should also be able to respond to an emergency within 30 minutes unless I am on vacation and relieved by another doctor. We are required to pay annual medical staff dues for this scheme which is renewable every two years. Part of the condition is that you are required to maintain a certain number of Credit hours of Medical Education (CME) through attending relevant seminars and conferences as well as through reading medical journals in one’s field.
Q What prepared you for all this?
A It started from my family setting. As I said earlier, I am the eight child in the family of 10 comprising six boys and four girls. All the boys are older than myself. So that is where the competition started. I was born to the family of Okafor-Ogbaji in Arondizuogu of Imo state. My late father was a teacher, while my mum was in private business. My mum was a very strict disciplinarian. I had my primary and high school education in catholic missionary schools. I went to Ihioma Girls’ School in Ihioma, Orlu. With time I have learnt to live with the demands of my profession and family life.
Q How do you really unwind?
A Well I undertake a regular exercise and I also do a lot of work in the home. I enjoy cooking and I also try to rest whenever possible.