[SPECIAL REPORT] Surgical Service In South West Nigeria - The Ibarapa Experience

Dr Oluyombo Awojobi

It is often forgotten and not well appreciated that Nigeria provided the blueprint for primary health care delivery to the world when the Faculty of Medicine, University of Ibadan, initiated the Ibarapa Community and Primary Health Programme in 1963.¹ This programme, based at the Rural Health Centre in Igboora, antedated the World Health Organization Alma Ata Declaration by 15 years.²

“In 1962, the University College achieved full university status as the University of Ibadan, and with the attainment of a full University Status, the University of Ibadan acquired the freedom to determine its own curriculum, and to award its own degrees. That period of change provided the occasion for a reappraisal by the medical school of not only the pattern and content of the medical curriculum but also of the objectives to be aimed at in medical teaching in a developing country such as Nigeria.

“It was against this background that the educational philosophy of the Ibarapa Community Health Project was conceived and the following specific objectives formulated:

1. To teach medical students and doctors, through practical work, the principles and practice of community medicine.
2. To study the problems of health care delivery in the Ibarapa Community and to develop the health services of the district into a model of what an integrated local health service should be, in collaboration with the government of Western Nigeria, in a manner which can be applied to other rural districts in  Nigeria and other developing countries.
3. To carry out research into various aspects of health and disease in the community, and thus to build up a body of knowledge on the various factors (social, economic, epidemiological, statistical) which are involved in health promotion and disease prevention in rural communities.” ¹

Therefore, the philosophy of the founding fathers of the University of Ibadan, Faculty of Medicine and her teaching hospital, the UCH, Ibadan, has always been community-centred and oriented in the traditional functions of research, teaching/training and provision of service.

These objectives are exemplified in this case scenario:

“A pregnant woman, in a rural community, attends antenatal clinic regularly and gets all the necessary promotive and preventive care until she is due for delivery. But suddenly at term, she starts bleeding. She is rushed in the village ambulance to the nearest general/district hospital where the resident physician performs a Caesarean section to deliver a live healthy baby(ies) and a surviving mother.”

In other words, it is primary care surgery that makes all the difference in primary health care delivery as typified in a short text in a secondary school book: “A minute on the theatre clock makes a great difference between life and death”. This was the statement that propelled Prof E F Alufohai, a former surgical resident at UCH, former provost, college of medicine and acting vice-chancellor of Ambrose Alli University, Ekpoma, to become the first professor of primary care surgery in Nigeria.³

There is often a misconception of what primary health care means. Most people believe it is executed by very junior health workers while others consider it inferior health care. On the contrary, as amplified by WHO, it is the care of the most common diseases found in the community, irrespective of their complexity, given as close to where the patients live, using scientifically sound and appropriate technology. In other words, as I often told medical students in the past, if brain tumours assume public health dimensions, the neurosurgeon must go into the community and deal with challenges as we and the Malawians have demonstrated with ventriculo-peritoneal shunt insertion for infantile hydrocephalus.⁴

This year, Ibarapa programme will celebrate the golden jubilee and so, it is time to assess, reappraise and consider for amendment several aspects of the programme.

MEDICAL TEACHING AND TRAINING IN IBARAPA

From the inception of the programme, Ibadan medical students would spend eight weeks in the district including one week at the District Hospital, Eruwa where they learned the rudiments of secondary health care. We proudly call ourselves Ibarapa graduates on becoming doctors. A significant proportion of doctors in Nigeria today, including the two rural surgeons in Ibarapa, are Ibadan-trained.

At the UCH, the training of the surgeon, which gave significance to the BS component of the degree, started at the undergraduate level because every medical student took part in the operation on his/her patient even in extensive procedures as abdomino-perineal resection of the rectum for carcinoma or colon replacement of the oesophagus for severe stricture. During his posting to the casualty department, he learnt to suture lacerations, incise and drain superficial abscesses and apply the plaster of Paris after manipulating closed fractures and reducing dislocations.

The acquisition of this hands-on experience continued during internship and residency training. In the first three years of the five-year residency training, he rotated through all the surgical specialties before gravitating into his specialty of choice. He also had three-month rotations in pathology (morbid anatomy) and anaesthesia in preparation for practice in resource-poor settings. During the rotation in pathology, the resident revised gross anatomy, performed various gastrointestinal anastomoses and inguinal herniorrhaphy before embalmment in requested cases. In addition, he undertook an in-depth study of surgical pathology.

The apparently comprehensive curriculum and the stiff examination processes resulted from the recognition that the poorer the available facilities, the greater the skills required in the practice of surgery. The surgeon working in isolation in a rural hospital with limited ancillary service triumphed only by a higher degree of technical competence, judgment and experience. He was well grounded and secure, more pliable, adaptable and improvising, that he might practise well not by surgery alone but also by active common sense.^{5 - 7}

The other functions of the academic surgeon were not left out in the training programme. The resident regularly taught the medical students and junior colleagues attached to his unit and would present a dissertation of an original clinical work for the final fellowship examinations that conferred a consultant status on him. Some of these dissertations were published in journals and text books.^{8 - 10}

The comprehensive education also explained the relative ease with which Nigerian-trained surgeons fitted into a more sophisticated practice after becoming familiar with new technology.⁷ The battle cry was TRAIN THEM HARD!!⁵

It was common for many residents who went to the UK for the optional one year abroad to write and pass the fellowship examinations of the Royal Colleges of Surgeons of Edinburgh or Ireland.

Grand rounds were held from 8.00am to 9.00am on Saturdays before everybody dispersed for social events. The proceedings were regularly published in the IBADAN SURGEON, an in-house journal, which was a veritable resource material for medical students who could not attend because of other postings outside Ibadan and also for incoming clinical students. The grand rounds were clearing houses for papers to be published in national and international journals and discussion forums for ongoing researches. They were antidotes against plagiarism.

The surgical textbook, COMPANION TO SURGERY IN AFRICA edited by Professor W W Davey,¹¹ a former head of the department, was truly a companion to the medical student and later the surgical resident in West Africa. The second edition, published in 1987, had senior registrars as authors of chapters.^{9, 10, 12 - 15}

The standard of surgical practice, teaching and research at the UCH, Ibadan was comparable to the rest of the world culminating in open-heart surgery by an all-Nigerian team becoming a routine in the early eighties.¹⁶ We were on the threshold of renal transplantation before the decline made it a mirage.¹⁷

That was the UCH where I had all my professional training from 1972 to 1983 declining the optional training for one year in the UK three decades ago. I was the only resident in the country that did not avail himself of that opportunity while it lasted.

This was a deliberate decision on my part because 26 of my 30 teachers (from senior registrars to professors) trained in the UK while the rest trained in the United States of America. They were all world renowned and I had implicit confidence that they could train their kind solely in Nigeria. 

Secondly, I volunteered to be the unsolicited control in a new training scheme that would provide a basis for future assessment of that aspect of the programme. One of my teachers put it like this in one of his lectures: ‘NO CONTROL, NO CONCLUSION in any scientific experiment.’¹⁸

Another source of inspiration was the ‘Red Devil’, the battle tank of the Biafrans that was deployed in battle from Aba, where it was made, until it got stuck at Ore during the civil war, 1967 - 1970. 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.

The most important inspiration was that I have always looked forward to a day like this when everything I am to talk about is home-grown in Ibadan and Ibarapa district with no foreign influence whatsoever. Although I had several opportunities to travel abroad for undergraduate and postgraduate training, I journeyed out of Nigeria for the first time in 1995. That was 20 years after becoming a medical officer and 12 years of being a rural surgeon.

At the end of my training in the UCH, I had 21 publications in national and international journals^{8, 14, 15, 19 – 36} including the subject of my dissertation for the fellowship in surgery in the prestigious American journal, Diseases of Colon and Rectum.⁸ My first paper was published in DOKITA.¹⁹ This paper, ‘The differential diagnoses of anemia. A review of two cases,’ arose from a seminar we had in haematology.

So, it was like going back home when I returned to the District Hospital, Eruwa in 1983 as a consultant rural surgeon, an employee of Oyo State government along with my wife, Atinuke, a radiographer and ultrasonographer, also a product of the UCH. In addition, I was appointed an Associate Lecturer in the College Medicine and became a honourary consultant to the UCH in 2007.

From 1983 to 2003, while my teachers were still in charge in UCH, medical students and surgical residents were posted to me on three months rotations. To the medical students, the crucial role of the surgeon at the primary and secondary levels of health care delivery, especially in the rural area, became clear. The residents acquired hands-on experience quickly and together we published papers on the common problems faced by the rural surgeon like inguinal hernia and frequency of twinning which was highest in Ibarapa district among other papers.^{37 - 48}

HEALTH CARE DELIVERY IN IBARAPA COMMUNITY

In 1970, the District Hospital, Eruwa was opened and secondary health care delivery was provided by UCH registrars from the departments of surgery, obstetrics and gynaecology. This arrangement was reinforced in 1975 by the appointment of the late Dr C A Pearson as the Chief Medical Officer of the programme by the Faculty of Medicine of the University of Ibadan.

Dr Pearson was the British medical missionary who developed the Wesley Guild Hospital, Ilesa to the high standard that enabled the Obafemi Awolowo University consider taking it over as one of her teaching hospitals complex.⁴⁹ He was also one of the founding fathers of the Faculty of General Practice of the National Postgraduate Medical College of Nigeria. He and his wife, Jean, resided at the Rural Health Centre, Igboora but performed elective surgery (mainly inguinal hernia repairs) at Eruwa.^{50, 51}

When I took up appointment at the district hospital in 1983, Dr Pearson literally handed the surgical baton to me while he moved on to Lagos to become the Director of Planning and Training of the new Faculty of General Practice.

In 1986, due to bureaucratic bottlenecks, I resigned my appointment from public service to establish Awojobi Clinic Eruwa in Eruwa with the mission statement “A PRIVATE HOSPITAL IN THE PUBLIC SERVICE”⁵²

At present, much of the medical/surgical services in Ibarapa are provided by private institutions manned by two rural surgeons (Drs A C Sagua and myself), two medical officers (Drs R O Tijani and M H Adabanija) who are capable of delivering safe and essential surgery, one medical officer, Dr L Siben with diploma in ophthalmology who is extracting cataracts at the Akeef ElMaghragby Eye Clinic, Eruwa, under the supervision of Dr B G K Ajayi, consultant ophthalmologist and president of our alumni association, one radiographer/ultrasonographer, two pharmacists, a few registered nurses and several Community Health Extension Workers, CHEW’s, who are the products of the revolutionary endeavours of the late Prof Olikoye Ransome-Kuti as Federal Minister of Health. All of us physicians, except Dr Adabanija (a graduate of Obafemi Awolowo University, Ile-Ife) are Ibarapa graduates.

Table 1 shows the surgical operations performed from 1983 - 2010. The climax in abdominal surgery was reached when the two synchronous combined abdomino-perineal resections of the rectum for carcinoma were successfully performed by the two rural surgeons in April 2009 and October 2010 in our rural hospital. On 29^thSeptember 2011, we successfully inserted a ventriculo-peritoneal shunt in a 17-month old child with congenital hydrocephalus.

Another problem associated with the decline in UCH was the gross delay in obtaining histopathology reports on operative specimens. By August 2003, we had 49 outstanding reports dating back to 2001. We had paid one thousand five hundred naira (N1 500.00) for each specimen.

Again, we have overcome that bottleneck by procuring the microtome and other accessories to produce the slides which are read by a pathologist in UCH.  Results are available within 10 days of obtaining the specimen by the routine we have established.⁵⁴ We have processed over 3 500 specimens in the last 8 years.

We offer preventive services as well in form of immunization for adults and infants and regular health education talks.

A medical student and I reviewed mortality at ACE from 1987 to 2001 analyzed at five year intervals, we found that the incidences of typhoid fever, gastroenteritis, infective hepatitis and cholera as causes of mortality dropped by over 80 per cent due to the intense and consistent health education we gave to the populace.⁴² There has been no cholera outbreak in rural Ibarapa district for over 15 years now even with no improvement in the municipal water supply and a recent outbreak in Ibadan.⁵³  

Since 2006, another Ibarapa graduate, Dr (Mrs) M Walker, has set up an NGO that assists people living with HIV/AIDS in Ibarapa.⁵⁴ 

From these elaborations, it can be deduced that 95 per cent of surgical patients can be taken care of in Ibarapa and it is a fact that there is now a reversal of the rural-urban drift in health care delivery in Ibarapa. Thus, it can be concluded that Ibarapa district has the best health care delivery system in Nigeria and it is a good example of the public/private partnership often touted to solve the health care and other challenges of Nigeria.

In 2009, we were the subject of an award-winning documentary, INNOVATING FOR AFRICA. UNCOMMON SERVICE!!

MEDICAL RESEARCH IN IBARAPA

From the inception of the programme in 1963, medical research has been the bedrock of health care delivery and has put Ibarapa on the global health map. This is the third objective of the Ibarapa Programme. To mention but a few:

In the 60’s, Emeritus Prof P P S Nylander, obstetrician and gynaecologist and my teacher, conducted a series of research into the phenomenon of twinning in Ibarapa district. He found that the Yoruba of Ibarapa had the highest twinning rate in the world (40 per 1000 live births) and the twins were of the fraternal (dizygotic) type. This meant that the women were having multiple ovulations in their menstrual cycles and could be triggered by environmental factors. He suggested these factors were in the local yam.⁵⁵

In 2005, at ACE, I was conducting a morning ward round with some Ibadan medical students and on the maternity ward were a Yoruba, an Igbo and a Fulani woman with twins. This triggered a review of our deliveries from 1986 to 2004 epitomizing Pasteur’s aphorism that: ‘Dans le champs de l’observation la chance ne favorise que l’intellingence prepare’ (‘In the field of observation (research), chance favours only the mind which is prepared’).  

Since the 60’s, there has been a steady influx of other Nigerian nationalities into Ibarapa but very few, if any, intermarriages. We found that these other nationalities had the same propensity to have twins like us, Yoruba. This result was published in the Nigerian Postgraduate Medical Journal.⁴⁶ The paper generated some interest on the internet.

The next stage in the research was to find out the factors in the environment responsible for the multiple ovulations in the women. I collaborated with a food nutritionist in the Department of Biochemistry of the University of Calabar, Calabar.

In the following four years, she made several trips to Eruwa and Igboora collecting the local yam and the popular edible vegetable, ilasa, to feed the experimental rats in her laboratory.  The outcome was the PhD she obtained in November 2011 and the two papers published.^{56 - 58} She confirmed that these food items caused the rats to produce more litters than the control group.

Like most basic researches, there are several spin-offs like the professor of agriculture in the university thinking of using the yam and ilasa to improve reproduction in cattle and other animals.

Dr Pearson found that onchocerciasis was a cause of musculoskeletal pains⁵⁹ and patients with pulmonary tuberculosis had facial hypochromia unrelated to the degree of anaemia but which resolved with specific therapy.⁶⁰ He described an effective method of inguinal hernia repair which had the same principle that formed the basis of the mesh repair.⁵⁰

Several other university teachers based in Ibadan conducted researches in Ibarapa that contributed significantly to their promotion.

At ACE, we have firmly established the specialty of primary care surgery (which I prefer to call rural surgery) in Nigeria and in the process brought appropriate technology in health care delivery to the fore. In this respect, we have fabricated the operating table that uses the mechanical jack for elevation and depression,⁶¹ the manual haematocrit centrifuge from the bicycle wheel,⁶² the hospital still using copper tubing,⁶³ the modified trocar and cannula,⁶⁴ the intraosseus needle,⁶⁵ the atraumatic suture from nylon and hypodermic needle⁶⁶, the autoclave powered by maize cob furnace and the pedal suction pump using the bicycle valve.^{67, 68}

In 2008, Bells University of Technology, Ota, Nigeria, a private university, honoured me as the Foundation Lecturer and thereafter set the pace in offering courses in biomedical engineering. I am an associate senior lecturer in that university.

In addition to publishing over 60 papers since arrival in Eruwa, I have been privileged to be the third editor, the author of eleven chapters and the publisher of the third edition of the standard textbook, COMPANION TO SURGERY IN AFRICA⁶⁹ and a book, PRIMARY HEALTH CARE IN WESTERN NIGERIA 1977 – 2007, commemorating the 21^st anniversary of ACE.⁷⁰

THE CHALLENGES

Having worked in a rural area of Ibarapa district of Oyo State for 28 years, the challenges of rural health care delivery in our country include:

1. The activities of professionals allied to medicine, traditional healers, bone setters, alternative medical practitioners and ordinary citizens who belong to none of the above but provide medical and surgical services.⁷¹
2. The low morale of medical practitioners in the rural areas.
3. The level of competence required of a medical officer to perform effectively in the rural setting and deal with above case scenario of the pregnant woman in the village. Records at the Medical and Dental Practitioners’ Disciplinary Tribunal show that over 95 per cent of the cases were for operations that went wrong, though many of the procedures were not necessarily performed by doctors with formal surgical qualifications.⁷²
4. The prospects for professional advancement while still based in the rural setting.
5. The infrastructural inadequacies in the health institutions.
6. The inappropriate administrative milieu in the health institutions.
7. The social problems of raising a family and securing a job for the spouse in the rural setting.

PROPOSED SOLUTIONS

Our proposed solutions include:^52,73,74

1. Activities of non-physicians.

These fellow Nigerians are inevitably responding to the phenomenon of WHERE THERE IS NO COMPETENT DOCTOR which is a variant of the dictum NATURE ABHORS VACUUM. Legislation will not solve the challenge as those who will make and enforce the law patronize them. However, the government can control the content of their advertisement and vet all programmes from such sources before broadcast to prevent the dissemination of inaccurate information to the populace. Statements that claim to cure hypertension and diabetes mellitus should not be heard in present day Nigeria. The eventual solution is to TRAIN THE DOCTORS HARD to deliver safe and essential surgery and EDUCATE THE POPULACE HARD to know their rights and responsibilities.

2. Morale of rural doctors.

In order to motivate and attract doctors to the rural areas and urban slums, the MDCN should put a moratorium on the payment of renewal fees for accredited doctors working in such disadvantaged circumstances. It should insist on acquisition of points from continuing professional development courses after the training institutions and universities have initiated postgraduate training courses in primary care surgery.

Putting an undue and inappropriate financial obligation on the Nigerian rural doctor is not good for his psyche while he battles daily with the atrocities of his non-physician compatriots who, without fetters, practise orthodox medicine next door to him and cause epidemics of faecal fistula,⁷¹ vesico-vaginal fistula, gangrene of limbs, etc. I would choose to retire than conform to such directive.

On the issue of remuneration and having been self-employed and an employer of labour for 25 years, I am of the opinion that in any system, remuneration should be based on productivity and where this is not so, ‘what is good for the goose should be good for the gander’. A situation where a councillor, who barely completed secondary school education, is earning multiples of a doctor’s salary does not make for equity. I support the doctor who is fighting for equity with all the legitimate means at his/her disposal.

The Hippocratic Oath, often evoked to castigate striking doctors, presupposes that the physician is well psychologically, mentally, socially and physically. But, that cannot be said of a doctor who is owed several months’ salary.

3. Level of competence.

The current training programme that produces a full-fledged general surgeon or a family physician is not adequately coping with the magnitude of the health challenges in rural Nigeria.

The need to train middle level surgical manpower specifically to address these challenges has been examined and debated for many years.⁷⁵ The Malawians have been more pragmatic in this regard having successfully trained non-physician clinical officers to insert ventriculo-peritoneal shunts to treat hydrocephalus in children, resect and anastomose bowel in strangulated inguinal hernia and perform transvesical prostatectomy for benign prostatic hypertrophy.⁴ Their outcomes compare favourably with those performed by surgeons. My teacher, Emeritus Prof A Adeloye, a neurosurgeon, taught the Malawians how to insert the VP shunt.

4. Professional advancement.

The frame work should provide for opportunities to undergo more training with the ultimate goal of becoming a consultant surgeon or family physician if so desired.

It is proposed that the structure of training at the National Postgraduate Medical College of Nigeria, the West African College of Surgeons, WACS and the West African College of Physicians be in stages and decentralized with accreditation of more nongovernmental health institutions for the training of specialists and middle level manpower. Only the Faculties of Ophthalmology and Anaesthesia of the WACS have moved decisively in that direction with the diploma in the specialties. Certificates should be awarded for successful completion of each stage viz: diploma, membership and fellowship which should reflect appropriate degree of professional competence. These certificates should be registrable with the MDCN.

The major advantages of this scheme include:

a. Residents do not stay for five to six years in tertiary institutions during which they behave like career officers who specialize in labour union matters. Many tertiary and public hospitals are closed for most of the year due to the demand of doctors for increased salaries.

b. More opportunities are created for training middle level man power for services in rural and remote areas.

c. Non-governmental hospitals with underutilized surgeons and family physicians (who practise primary care surgery) will become training grounds for service and research.

d. The products will be fully prepared to work at all levels of the health care pyramid. A staged training programme will be more acceptable in keeping the medical officers in the rural setting.

e. The critical mass to achieve the MDG's will be attained sooner than later.

The various institutions (teaching/tertiary) for training surgeons are facing difficulties due to deteriorating infrastructure and diminishing access to surgical care through prohibitive user fees which have altered their bed occupancy and changed the frequency ratio of diseases for the balanced experience of surgical trainees^{7, 76}. Therefore the revitalization of the teaching hospitals is crucial at this moment so that the prohibitive user fee does not turn away patients that should be managed at this level.

The universities, especially the National Open University of Nigeria, should be encouraged to initiate the more apposite Master of Science (Primary Care Surgery) programme similar to the Master of Public Health, MPH, degree. This will allow for the academically inclined rural practitioner to seek employment in the university after providing service and undertaking research in the rural area.

The colleges of medicine should, as a matter of urgency, create Departments of Family Medicine but the faculty staff should be based in rural health institutions.

Recently, the one year training abroad was reinstated. A review of that aspect of the training in the 80’s, of which I was the unsolicited control, would show that it is not necessary in today’s Nigeria. It will only encourage the flight of more Nigerian doctors abroad with the resultant deterioration in the human resources for health that this symposium aims to solve. There is hardly any type of surgical care that is not available in Nigeria today and several of the superspecialists abroad are our compatriots.

5. Infrastructural inadequacies.                                                                                                           The challenges of infrastructure and medical devices have been fully solved at ACE such that foreign NGO’s have found the setup satisfactory enough to regularly conduct hernia and eye surgery missions at ACE.^{77, 78} We need to replicate them in all the rural hospitals of our country.

6. Inappropriate administrative milieu.

The administrative structure in operation at present in the public service is inimical  

to the efficient running of rural health institutions. Governments should be encouraged to adopt the Bamako Initiative of revolving funds in the procurement of materials needed to efficiently run rural health institutions.

We initiated the Bamako initiative at the District Hospital, Eruwa (1983 – 86) four years before its conception and continued in our private clinic from 1986 to date.⁷⁴

Accountability in financial matters could be assured by the open accounting system in which ALL members of staff and some representatives of the community constitute the auditing team that meets EVERY month and the medical officer in charge sends written reports signed by ALL heads of departments quarterly to the state and local headquarters. Involving the junior staff is an antidote to embezzlement and other corrupt practices.

7. Social challenges.     

The social challenges of raising a family are critical to retaining medical officers in rural areas. However, we have shown that it is safer, better and cheaper to do that in the rural area where there is a constant relationship between parents and their children while they are growing up.

Our two sons went to public schools although; there were private primary and secondary schools in Eruwa. The older, an electrical/electronics, biomedical engineer, graduated from Obafemi Awolowo University, Ile-Ife  and the younger graduated a physician from the same university in 2012.

There should be close collaboration between the governments at the three levels and the private sector in the rural setting to provide job opportunities for the spouses (usually the wives). Where the wife decides to be self-employed, soft loans from the banks should be guaranteed by the employer of the husband.

CONCLUSION

We have shown that the Ibarapa Community and Primary Health Programme of the University of Ibadan has achieved its stated objectives in the spirit of community participation and the public/private partnership. What is left to be done is for all the ministries of health in the nation to take the bull by the horn and replicate the programme in all the local government areas.

The training programmes of the postgraduate institutions “must be relevant, flexible, and adaptable to reflect our needs at all the three tiers of the health care system while we cannot lose touch with new developments and technologies that can be used to manage the changing patterns of disease or the emergence of a new pandemic of diseases common in industrialized countries. The ability to make virtue out of necessity is the greatest and immediate challenge of all”.⁷

About The Author

Dr Oluyombo Awojobi had his professional training at the University College Hospital, Ibadan where he graduated in 1975 with distinction in surgery. He was a university scholar after the first MB, BS university examinations. He also earned the prestigious Adeola Odutola prize for the best final year medical student. He is a rural surgeon, entrepreneur, innovator, inventor and advocate for quality surgical education in developing countries. The journal Africa Health in the September, 2005 issue described him as “the architect, builder, surgeon, doctor, maintenance man, proprietor, and Chief Dreamer of the Awojobi Clinic Eruwa (ACE) in rural South West Nigeria.” Since 1983, he has worked as a surgeon at the District Hospital Eruwa in rural Ibarapa district of southwest Nigeria for three years before setting up his own practice in Eruwa in 1986. Dr Awojobi provides a model for sustainable surgical care in rural areas to the International Collaboration for Essential Surgery through his life’s work, ACE.

REFERENCES

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2. Primary Health Care. Report of the International Conference on Primary Health Care, Alma-Ata, USSR, 1978.
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4. Wilhelm T J,^, Thawe I K, Mwatibu B, Mothes H   and Post S   Efficacy of major general surgery performed by non-physician clinicians at a central  hospital in Malawi Trop Doct 2011; 41: 71 – 75.
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6. Solanke T F Training of medical practitioners in Nigeria (West Africa) for surgery in the rural areas. S Afr J Surg. 1997; 35: 139 – 141.
7. Ajayi O O and Adebamowo C A  Surgery in Nigeria. Arch Surg 1999; 134: 206 – 211.
8. Awojobi OA. Modified pile suture in the outpatient treatment of hemorrhoids: A preliminary report.  Dis Colon Rect 1983; 26: 95- 97.
9. Funmilayo J A Salivary gland tumours In Davey`s Companion to Surgery in  Africa. Adeloye  A. (editor) 2^nd edition. Churchill Livingstone, London. 1987. 209 – 214.
10. Alade R B, Itayemi S O and Alufohai E Hernias ibid 387 – 405.
11. Davey W W Companion to Surgery in Africa. Davey W W (editor). Churchill Livingstone, Edinburgh and London. 1968
12. Alufohai E. Amoebiasis. In Davey`s Companion to Surgery in    Africa. Adeloye  A. (editor) 2^nd edition. Churchill Livingstone, London. 1987. 349 – 358.
13. Alufohai E Abdominal injuries. Ibid 406 – 411.
14. Awojobi O A. Intussuception.   Ibid 324-334.
15. Awojobi O A and Adeloye A. Gastrointestinal tuberculosis, lymph glands and    lymphatics. ibid 379-386.
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25. Awojobi O A, Nkposong, E O and Lawani J. Aetiologic factors of male infertility in Ibadan, Nigeria. Afr J Med med Sci 1983; 12: 91 – 94.
26. Awojobi O A, Ogunbiyi O A Nkposong E O. Unusual relationship of multiple renal arteries. Urology 1983; 21: 205-206.
27. Awojobi O A Junaid T A and Nkposong E O. Transrectal biopsy of the prostate: A review of 186 biopsies.  Afr. J. Med med Sci 1983 12: 117-119.
28. Awojobi O A , Akinsola A, Ogunbiyi C O and Nkposong E O Recovery of renal function after 33 days of complete bilateral ureteric obstruction. Afr. J. Med med Sci 1983; 12: 121-12. 
29. Awojobi O A, Lawani J, and Nkposong E O. Single dose gentamicin and metronidazole in the prevention of wound sepsis in urological surgery.  W Afr J Med 1983; 2: 97 - 100.
30. Awojobi O A and Itayemi S O. Abdominal incisional hernia in Ibadan. Trop Doct 1983; 13: 112 – 114.
31. Awojobi O A and Ayoola E A. Management of primary liver cancer: A review of current approach with particular reference to the tropics.  Nig. Med. Pract. 1983; 6: 135-139.
32. Awojobi O A   Abdominal tuberculosis in the African     W. Afr. J. Med. 1983; 2: 159-163.
33. Awojobi O A Use of Foley catheter in suprapubic punch cystostomy: An adaptation. Trop Doct 1983; 13: 189.
34. Awojobi O A and Lawani J. Suprapubic cytostomy: indications and complications.  Trop. Doct. 1984; 14: 162- 163.
35. Awojobi O A, Akingbehin N A and Okubanjo A O. Vesical calculi in childhood: An unusual presentation. Nig Med Pract 1984; 7; 52 – 53. 
36. Awojobi O A and Nkposong E O.  Seminal fluid changes after testicular torsion. Urology 1986; 27: 109 – 111                                         
37. Awojobi O A, Sagua C A and Ladipo J K. Outpatient management of external hernia. A district hospital experience. W Afr. J. Med 1987; 6: 201-204.
38. Awojobi O A, Ladipo J K and Sagua C A. Paediatric inguinoscrotal surgery in a district hospital. Trop Doct 1988; 18: 23-24.
39. Awojobi O A and Ogunsina, S   Ectopic pregnancy in a rural practice.  Nig J Med  2001; 10: 139 - 40.
40. Awojobi O A, Ogunsina, S and Adekola, F  Ectopic pregnancy in a rural population with a high twinning rate.  Trop Doct  2002; 32: 37 -8.
41. Awojobi O A and  Muyibi SA  Letter.  When there is no plasticine  Trop Doct  2002; 32: 250.
42. Awojobi O A and Olaleye O A  Causes and trend of mortality in Ibarapa.    Dokita 2003; 29: 53 - 56.
43. Awojobi  O A and Ayantunde A A   Inguinal hernia in Nigeria. Trop Doct  2004; 34: 180 – 181.
44. Tokode O M and Awojobi O A Spontaneous appendicocutaneous fistula – A case report. Ann Ibadan Post Grad Med 2004; 2: 48 – 50.
45. Awojobi O.A and Ayantunde A A Outpatient simultaneous bilateral inguinal herniorrhaphy in a rural practice.     Niger J Clin Pract  2004; 7: 28 - 30.
46. Awojobi O A, Jeje O M, Oti O O, Dania S,  Dada O, Gbadamosi O A, Ajayi N O, Madu B E, Akanji T O and Adewumi B A The frequency of twinning in a rural community in Western Nigeria – an update.  Niger Postgrad Med J 2006; 13: 73 – 74.
47. Awojobi O  A, Sagua A C and Ogidiagba E L. Inflated inner tube in the prevention of pressure ulcer. Rural Surgery 2008; 4: 17 – 18.
48. Awojobi O A and Ogunsina G S. Chronic lymphoedema.  In: Davey`s Companion to Surgery in Africa. Adeloye A, Adekunle O O andAwojobi O A. (editors) 3^rd edition. Acecool Medical Publishers, Eruwa, Nigeria 2009, 92 – 106.
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53. Awojobi O A  Letter: Pragmatic option for preventing water-borne diseases in Nigeria. Afr Health 2011; 33: 12.
54. Walker M  E  Rural aids care and treatment access project (RACTA project): A semi-annual report, November 2006 - May 2007. In:Primary Care Surgery in Western Nigeria 1977 – 2007. Awojobi O A (editor) Acecool Medical Publishers, Eruwa, Nigeria 2007,
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56. Lawal O O Nutritional evaluation and reproductive studies of white guinea yam (Dioscorea rotundata) diets in albino wistar rats. PhD thesis, Department of Biochemistry, University of Calabar, Calabar, Nigeria. September 2011
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60. Pearson C A  Hypochromia as a clinical sign of tuberculosis in the tropics. Tubercle 1978; 59: 111 – 119.
61. Awojobi O A   Appropriate technology for operating tables. Afr Health 1994; 16: 17-19.
62. Awojobi O A   The manual haematocrit centrifuge.  Trop Doct  2002; 32: 168
63. Awojobi O A   The hospital still. Trop Doct. 1993; 23: 173-174.
64. Awojobi O A   Letter. Suprapubic cystostomy- Another adaptation.  Trop Doct 1986; 16: 180.
65. Awojobi O A  Letter. Epidural needle and intraosseous access. Trop Doct 2003; 33: 59.
66. Awojobi O.A   Letter. Atraumatic sutures can be made locally. Trop Doct   2005; 35: 124.
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68. Awojobi O A Engineering fabrication in Nigerian rural medical practice – The Eruwa experience. LAUTECH J Eng Tech 2007; 4: 58 – 62.
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71. Gyoh S K An epidemic of faecal fistulae.. Africa Health 2011; 33: 8.
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