Hospitals in the bush

{jathumbnail off}Since 1983, surgeons working in rural Ibarapa district of Oyo state, have done over 11,900 surgeries armed with nothing but the most the most basic and sometimes unthought-of equipment.Dr Oluyombo Awojobi is one of four general surgeons who coopted some junior colleagues in rural-urban slum practice to form the Association of Rural Surgical Practitioners of Nigeria with 14 foundation members in 2008.Last week, he picked up an award for rural-based health workforce achievers on behalf of the association for its work where there are no doctors.Five more awards were offered to healthworkers in similar circumstance in different rural areas and urban slums around the country: Deborah Badu, a junior community health extension worker for her work helping build an outreach programme to cover 18 villages in Fuka Munya, Niger; and Yagana Wali, chief nursing officer of a 20-bed clinic providing antenatal care, immunisation and community empowerment in rural Borno.Others are Zulai Sani, a community health extension worker in Machina, Yobe; and the National Primary Healthcare Development Agency for its Midwifery Services Scheme which has dispersed nearly 2,500 midwives since 2009.The awards were presented by the federal health ministry and its development partners, including UKAID, USAID, the Carter Centre, PATHS II and others.http://www.youtube.com/watch'v=hasM7RPMfZYInspired by warDelivering healthcare to millions of patients in rural areas remains difficult, but few healthworkers are stepping up to the plate'and fewer still are being recognised for it.After training at University College Hospital, Ibadan, Dr Awojobi became a rural surgeon in 1983 in Eruwa, where he started rural practice on land provided by the locals.Apart from a first trip overseas in 1995'12 years after becoming a rural surgeon and 20 years after becoming a medical officer'he did his entire training in Nigeria, inspired by the notion that his world-renowned teachers could train their kind at home and a confidence that he could one day hold a lecture using only materials homegrown in Ibarapa district 'with no foreign influence whatsoever,' he once said in a guest lecture on rural surgery at Olabisi Onabano University.The third inspiration was something called the Red Devil, a Biafran tank deployed in battle from Aba, where it was made, until it got stuck at Ore during the Civil War.'I had inspected the disabled Land Rover-turned-battle tank at Ore and concluded that Nigerians could solve all their problems with little or no external help,' Awojobi said.But a surgery practice in the bush faced problems of water supply, electricity, sewage disposal and getting basic equipment.Public water supply was unreliable, a 90,000-litre overhead reservoir couldn't provide water round the clock and the hospital used 'bowls and buckets for most part of the day,' he remembered.The rural surgery overcame its water problems by harvesting rainwater using extra reservoirs and wells and pumping it through the hospital so it doesn't depend on municipal supply today.It also dammed a section of a stream that runs through the clinic and populated the dam with fish to control mosquitoes.One of two generators installed in 1970 broke down eight years later and its parts were cannibalised to maintain the second. And a 5KVA generator the clinic bought for N6,000 from operation fees and an appeal fund provided essential lighting but couldn't power the x-ray machine.The doctors have gone around lighting problems today by constructing the clinic's new site with large windows 'so that natural lighting is adequate to perform surgery in the daytime,' according to Awojobi. Good ventilation removes the need for fans and airconditioners.The clinic still uses inverters to power itself from direct voltage of car batteries, and is hoping one of its own will give it the solar panels it needs.Strokes of geniusStudents on rural posting from Ibadan have helped construct ventilation-improved pit latrines that staff and patients use at the hospital, cutting out the need for a water closet toilet when water is inadequate in supply.Other equipment around the clinic have taken some ingenuity and brought in awards of recognition.Its operating table'built in 1986 and named Olumide's table after a medical officer who suggested modifications based on the Mayo Trolley'is 90% wood and 10% metal and costs less than a tenth of standard cast iron tables. Topped with formica to make washing easy, it has won Innovation of the Year prize from Ikeja Jaycees.The hospital's autoclave, for sterilising equipment, and water distiller are made from cylinders of domestic cooking gas and powered by a coal furnace.Awojobi says it takes 20 minutes to autoclave materials, allowing nonstop surgery if gowns and linens are available. The distiller turns out 10 litres of distilled water every hour.The clinic also uses a suction pump fabricated from plumping pipe, a piece of leather and reversed bicycle valve. Its centrifuge is fashioned from the rear wheel of a bicycle. And it's been producing its own intravenous fluid'more than 60,000 litres to date at a tenth of their cost on the open market.Over the years, it has used the expertise of diploma holders in laboratory technology to produce specimen slides to be read by pathologists at UCH.Its method is thought much cheaper but just as effective. Its technician replace use candle wax in place of standard paraffin wax with candle wax to make tissue blocks, a razor blade in place of microtome blade and fix slices to glass slides over a small kerosene stove instead of an electric hot plate. Specimen results return in 10 days.And if you need hospital transportation, a village ambulance called the Autonov 3 is on call. The contrived tricycle is the third in its line after the Autonovs 1 and 2 in the 70s and 80s.Anaesthesia is a luxury for a rural surgeon, but it is available.What's being most constant is the human relations that run the clinic.Awojobi says relations stay with patients all day, offering nursing care and continual monitoring, though some have mischievously administered native drugs or taken medicines from home. There have also been local healers to deal with.Since they started, the rural surgeons have done over 12,000 surgeries. Only one in a thousand cases required referral, mostly to UCH and other specialists in Ibadan.'The referred cases included patients with cataracts, pterygia, a patient with complete heart block who had a pace maker successfully inserted at UCH Ibadan in 1984 but died at Eruwa District Hospital of severe enteritis some months later,' Awojobi admitted.The clinic has the services of cardiac surgeons and ophthalmologists, but it also sees dramatic cases now and again that challenge even the most skilled doctors: one woman had a plank transfixed in her chest after a road crash in 2002.Awojobi remembers the exact day: January 24, Friday. 'We stabilised her overnight, but due to the menace of armed robbers, we delayed her transfer to Ibadan till Saturday morning. But UCH was on strike. Eventually Prof Adebo, the cardiothoracic surgeon, and I started the operation on her at a private hospital in Ibadan at 2pm. This was eighteen hours after injury.'The woman died 12 hours after surgery 'due to severe stress and delay in intervening,' he told an audience during a lecture.It underscores a need for more healthworkers committed to using their skills in the remotest of places where only minutes matter between life and death.'Were the mobile telephoney available at that time and the night marauders not a factor,' the rural surgeon said, 'she might have survived.
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