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Interview with Dr. Ken Iregbu

ADEZE OJUKWU

Lagos, Nigeria

adezeo@yahoo.com

Thursday, November 4, 2004

Health correspondent Adeze Ojukwu spoke to Dr Ken Iregbu, a consultant at the National Hospital, Abuja on critical national issues. Here are excerpts:

To make an exhaustive assessment of Nigeria’s healthcare delivery system will entail looking at all aspects of activities that culminate in the delivery of an efficient, high quality, accessible and affordable heath services to the citizens. This will involve looking at the equipment and infrastructure, manpower, including the retraining of existing ones and the development of new ones to meet the challenges of modern health care delivery, cost and availability of services, funding of the system and the motivation of the personnel. The political will to do what is right at the right time using the right person is also an important factor in our healthcare delivery system. Without any fear of contradiction one can say that at the primary level there is nothing happening there in term of health care, except may be in some few primary health care centers where they still remember to do immunizations. The primary health care level is supposed to be the nearest care centres to the people particularly those in the rural areas. There is supposed to be a Medical officer in charge, probably working with one or two other doctors and assisted by other paramedical personnel. They are stationed at the headquarters and then visit the satellite clinics regularly to attend to minor health problem and refer the more serious ones to the secondary level where facilities and personnel are expected to be at higher levels. From the secondary levels cases are referred to the tertiary levels such as the teaching hospital where we are supposed to have a concentration of our best brains and the state-of the-art facilities; but what do we have? Archaic and dilapidated equipment at both the secondary and tertiary levels, good enough to establish tourist museums. Common things like water and electricity are still far from being sufficient for work. Even good furniture to sit and work on in a relaxed position are not available in most centres. The brain drain is still in progress; our experienced medical personnel are still emigrating in large numbers because of harsh working conditions, frustration and lack of job satisfaction. Quality research which is the cornerstone of medical excellence, both in practice and training, has almost become a mirage. About twenty years ago we were told that our hospitals had become mere consulting clinics; today there is even no body to consult again in some areas. About two to four weeks ago a chief medical director in one of the teaching hospitals in the east cried out that the staff have deserted the hospital to set up their own clinics and shops around the hospital. Training of medical and para-medical personnel has suffered greatly. Medicine has been very dynamic in the last two decades such that those who never took training seriously are obviously far behind time. You still find people taking medical decisions or carrying out procedures based on out-dated information and technique. The products of some of our medical schools are nothing to write home about. In a good number of them you find people who never studied medicine teaching core clinical subjects to students who are going to graduate as doctors. What kind of doctors will they be? Are we interested in quality or quantity? I am an examiner in Laboratory Medicine at National Postgraduate Medical College of Nigeria and the West African College of Physicians. The performance of candidates in these examinations gives a glimpse of the imminent danger in the health sector. The complaints are the same in all the faculties of the colleges. At the root of all the complaints is a very poor medical training foundation, principally due to the use of wrong teachers and poor training facilities in such core subjects as Pathology which is the basis of the understanding of the meaning of symptoms and signs leading to the correct diagnosis of diseases. If the foundation is poor the righteous can do nothing. One can go on and on. At the root of all the problems in the health sector is poor funding and politicization of issues. No objectives, no targets, no long-term planning. Everything is done on ad-hoc basis. No body can tell you for certain how many doctors or nurses this nation will require in ten or twenty years time from now. The middle level cadre staff in the health sector in a continuous battle to displace the key health personnel; a kind of rat race f you like. The administrators are busy issuing circulars and orders that actually impede progress. These are done without any consultation or consideration of the impact of such negative actions. If the cleaners can talk to the right people (lobbying) they will ask them to become directors. So there is confusion all over the place and nothing good ever comes out of a confused state. Before 1976 the University College Hospital Ibadan used to be the fourth best hospital in the whole Commonwealth nations. Today only God knows if it is even listed among hospitals. Our people are still dying in large numbers of preventable diseases. Our infant and maternal mortality rates remain the highest in the world. Every day people gather in five-star hotels from one city to the other talking about one aspect of health or the other, and at the end the talks translates to virtually nothing. NGO has become a booming business for people who ordinarily should have no business talking about health. Fund that could have gone a long way in addressing some major lapses in our health system are shared out to NGOs. One can go on an on. We are only hoping that the health reforms of this administration will address some of these ugly issues.  

This blackmail against the doctor is being championed by the same people who worked and are still working together to destroy the fabrics of our economic life. I will boldly tell you that the reason why our hospitals have not been shut down is because of the administrative prowess and patriotism of the doctors. More than thirty banks became distressed in this country yet no one has told us that the accountant or the economist is a bad manager and none of the Managing Directors was a doctor; over 80% of all the industries in this country closed shop, none of them was managed by a doctor, our transport corporations, airlines, NEPA, NITEL, schools including universities are either down or down and out; none was managed by the doctor. The doctor was not in charge of road maintenance; no doctor has ever been the Head of Service of either a state or of the Federation. In which of these has the managers done better than the doctors have done in the hospitals. Let me tell you that apart from poor funding the bulk of the problems we have today in our hospitals revolve around the support staff in administration. There are a lot of doctors with Diplomas and Masters in public and Business administration; I think that the time has come for doctors to take over the leadership of the administration section of the hospitals too so that things could be simplified and smoothened out. The hospital does not function well under a complex bureaucratic system, and that is what our administration is noted for. Don’t forget that the World health Organisation has always been headed by a doctor and one of our own the late Prof Adeoye Lambo, a doctor, was a Deputy Director General of the body for a long time. During the colonial era the Governor General always headed over state matters to the Medical officer of Health of the Federation each time he away from the country. Some of the first republic politicians such as Dr Michael Okpara and Dr Akanu Ibiam we eulogize today for their developmental and administrative visions and patriotism were doctors. When the late Prof Ransome Kuti laid a very good foundation for the growth of our health care system he did it from the standpoint of a doctor and not as degree holder in history or English or what have you. Even today amongst the governors that have been variously honoured (whether fake or real) for their achievements in their states are the two doctors amongst them, Govs Nnamani of Enugu State and Odili of River State. The very training of a doctor makes him a good administrator. After all what is administration; using the right resources to do the right thing at the right time based on established rules and regulations with a view to achieving set objectives. That is essentially what we do in patient management. It is indeed ridiculous and a paranoid feeling on the part of a man who read French or Theatre arts or Igbo Language and allied courses to think that he will manage a hospital better than a man who sat down to read medicine for six to 13 years. Enough of the blackmail. What people want to come and do in the hospital is to award contract for the painting of the fence instead of buying equipment for patient care; budget 500 million Naira for tea and coffee and ten Naira for drugs. I think the experience government had with contracting National Hospital Abuja to foreign hospital management experts, the International Hospital Group (IHG) is enough to make them ignore all the selfish calls for headship of the hospital to be everybody’s business. The so called experts who were not doctors but economists and financial experts were kicked out for non-performance. They could not do up to 40% (by my own assessment) of what our Nigerian doctors I management could do. I believe the failure of IHG was a big confirmation of the high quality managerial ability of the Nigerian doctor. We are health experts and we are managing our health institutions well giving the scarce resources available and the organised sabotage by some paramedical groups to discredit the doctors.  

I will elaborate on that using just one example. Pathology is a medical science that deals with the causes, development and progression of diseases that culminate in the manifestation of signs and symptoms. It is the manifestation of signs and symptoms that make you know that something is wrong with your body and therefore needs to consult the doctor. On getting to the doctor you complain about the way you feel, ie you tell him about the symptoms. He asks you some questions concerning the symptoms and other parts of your body. He then examines you to check for other features of the diseases or the presence of any other disease that has not yet developed symptoms, ie the signs. At the end he ties all the symptoms and signs together to narrow down to the diagnosis. He might request for tests or other forms of examination to either determine the stage of the diseases or fine tune the diagnosis if it is not yet clear. Tests may also be requested to determine he ability of the patient to withstand treatment in some cases or to monitor the effect of treatment. One disease can present in many ways, and many diseases can present in similar ways. It is the duty of the doctor based on his knowledge of Pathology to decide which disease is causing the patient’s symptoms and signs. Without a good knowledge of Pathology disease diagnosis becomes almost impossible. A good doctor must have a good knowledge of Pathology, and where a good doctor ends is where quackery begins. So Pathology is central to all aspects of Medicine, and that is why the Pathologist is called the doctors teacher or the doctor of final diagnosis. Now what is happening is in a lot of our medical schools is that they are using make shift teachers who never studied Pathology or even Medicine to teach this critical subject, and you cannot be a Pathologist unless you are first a doctor. What we have today in those schools is like telling an artist to teach a student of Architecture how to design and draw a high-rise building because everything is about drawing or to recruit a draughtsman as a lecturer to teach building designs to engineering and Architecture students. The situation is dead serious and needs urgent intervention. No matter how long a court clerk works with judges and magistrates he cannot suddenly transform into a lawyer or magistrate or judge. He must follow due process. For a draughtsman to become an Architect he must also follow the due process of education. So you cannot be a teacher of Medicine if you were never read Medicine. These universities are just pushing poorly tutored doctors into the society. The consequences will manifest very soon. We better halt the evil now. 

Incidentally I am a Pathologist (Laboratory Medicine Physician). At our last AGM in Port Harcourt in February this year we issued a communiqué drawing the attention of government to this ugly development. We had reasoned then that every University in Nigeria must not have a Medical school because the qualified and experienced teachers are not available to man the necessary positions to ensure the graduation of high quality doctors. The equipment or facilities for training are also grossly deficient. But the politics of the day seem to have made the leaders of these institutions to look the other way while things continue to deteriorate in their presence. The appointment of Vice Chancellors, Provosts, Deans and even Heads of Departments have all been politicized. The result is that the officer in question is not free to take decisions but must do the bidding of his mentors, whether he believes in it or not. The politicians will always want to embark on some of these projects like establishing universities and medical schools not because they want to make it happen but to score cheap political points. This is too common with State governments. The other aspect of it is that the Medical and Dental Council of Nigeria (MDCN) which is the body charged with the responsibility of regulating the teaching and practice of Medicine appears not to have uncovered the tricks of these institutions. During accreditation visits some of the institutions embark on borrowing or renting of staff and equipment to position them for the purpose of securing accreditation, only to dismantle them as soon as the team boards their transport back home. It may also be that the council has been facing some pressure from above to grant accreditation where the minimum requirements were not met. It is left for the Council to put its feet down and explain the dangers of being compelled to do so whenever they encounter such pressures

People should understand that a badly trained doctor in Enugu or Sokoto or Maiduguri is a public health hazard to everybody in the environment where he works, and who knows where he is going to work and when. So the establishment and approval of Medical Schools should not be looked at in terms of geopolitical location or other pecuniary interests but on need and availability of the necessary manpower and facilities to produce high quality doctors for the nation and even beyond. Only recently the Council of Legal Education announced that it will not accredit any new Law Faculty in any university in Nigeria for the next ten years, and will even embark on a thorough re-assessment of existing ones with a view to de-accrediting those that fail to meet minimum requirement necessary for adequate training of lawyers. This decision was informed by the fact that the quality of lawyers being produced these days was uncomfortably low. The MDCN needs to quickly toe the line of the Council for Legal Education. 

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