Rural Generalist Medicine and Political Will in Africa

Sub-Saharan Africa presents two contrasting pictures of Rural Generalist Medicine. The governments and the peoples of East and Southern Africa have demonstrated pragmatism while in the West African sub-region, the outstanding gains of the pioneers of modern medicine since the mid-19th century (1) have been replaced by outright retrogression and professional turf protection. (2) 

Since nature abhors vacuum, ordinary citizens, especially in Nigeria, have moved in under various guises to perform the roles of physicians including surgical operations. They couch more eyes with cataracts than all the ophthalmologists. They cause epidemics of faecal fistula complicating appendectomy. (3) The bone setters who, in the past, limited themselves to closed fractures now deal with cold orthopaedics and all forms of trauma with disastrous consequences in loss of lives and limbs. (4) 

The medical schools have degenerated to the point that new graduates have little or no skills and are not confident or capable to head the health team at the primary or secondary level where most of the population resides. They are called BABY DOCTORS by their patients and are responsible for 95 per cent of cases brought before the disciplinary tribunal of the regulatory body. (5) Those who want to improve their knowledge and skills find the residency training so constrictive and centralized such that they are waiting for several years to get training posts. In the meantime, their passes at the first professional exam could lapse after five years of inability to advance. 

The populace has lost faith in orthodox medical care while alternative medical practitioners and faith healers are in the ascendancy, even securing a seat on the official regulatory body that does not understand their modus operandi and which board has been dissolved for over two years. 

One of the surgical pioneers, in a recent lecture, lamented: "When we borrowed the pragmatic option of the Bamako Initiative of the World Health Organization (WHO) and introduced its extension from drugs into catering services, laboratory sciences, diagnostic and curative services in order to recover costs (otherwise known as a cost-recovery programme), we sought only to guarantee the steady availability of the basic tools of healthcare. 

We never envisaged the induction of a commercial mentality that has reduced out-patient attendances, eroded the hospital bed-occupancy ratios, which have now undermined undergraduate clinical exposures, diminished the opportunities for the acquisition of hands on skills, accentuated the dissonance between primary, secondary and tertiary healthcare and changed hospitals from the haven of compassion into money-spinning commercial enterprises.(6) 

While pragmatic solutions which have been practiced for over three decades by individual physicians in rural and semi-urban practices have been proffered, (7 -12) the present leaders are not receptive to new methods and are incapable of sustaining proven pragmatic options. The East and Southern Africans, realizing they could not train enough physicians to solve the challenge of health care delivery in the rural setting, resolved, over two decades ago, to train clinical officers for specific tasks like Caesarean section, appendectomy, repair of groin hernia that may even require bowel resection and anastomosis, open prostatectomy and insertion of ventriculo-peritoneal shunt for infantile hydrocephalus. 

Several reviews have shown that the outcomes of the efforts of the clinical officers compare favourably with those of the specialist surgeons. (13,14) It is pertinent to note that several Nigerian surgeons have been involved in the training of the clinical officers. 

In order to improve the Nigerian rural medical practice, the solution can be found in the words of my teacher and mentor, a former president of the West African College of Surgeons, Prof O O Ajayi: "For postgraduate medicine to impact on health, we must address the need to acquire appropriate cognate and hands-on skills within the reality of our social and economic circumstances. We cannot wait for adequate infrastructure, we cannot wait for the latest advances in hardware and we cannot wait for the levels of social and economic development which produced the healthiest nations on earth like Norway and Canada. 

While the processes of evolutionary advances subsist, we must shore up our value systems, upgrade our attitudes to public services, care for interpersonal relationships, sharpen our innovative instincts and regain the trust of our patients.(6) The ability to make virtue out of necessity is the greatest and immediate challenge of all (15).

REFERENCES
1.    Ajayi O O, Quartey J K M and Adebonojo S A. (editors) Knife in Hand. The
History of the West African College of Surgeons (1960 ­ 2010).  BookBuilders.
Editions Africa, Ibadan, Nigeria 2010. 
2.    Awojobi O A The birth of Medical Records at Awojobi Clinic Eruwa  - March 2012
 http://www.ifrs-rural.com/MEDRACE.pdf 
3.    Gyoh S K Epidemic of faecal fistula in Benue State of Nigeria. Africa Health
2011; 33: No 4)
4.    Boy, 7, loses hand to bone setters
http://www.tribune.com.ng/news2013/index.php/en/health-news/item/18006-boy,-7,-loses-hand-to-bone-setters.html

5.    Gyoh S K Avoiding legal pitfalls for the surgeon.                             
                                    
http://www.ifrs-rural.com/PROGRAMME%20BOOKLET2008.pdf  page 31.
6.    Ajayi O O Postgraduate Medical Education in West Africa. AIM Honours Lecture
2012. ISBN 978 978 921 018 3 
7.    Awojobi O A Human resources for health in Nigeria - Surgical skill acquisition
at ACE - June 2012  http://www.ifrs-rural.com/MEDRACE%20-%202.pdf 
8.    Awojobi O A Human resources for health in Nigeria - Surgical skill acquisition
at ACE (2)- September 2013 http://www.ifrs-rural.com/MEDRACE%20ISSUE%20SEPTEMBER.pdf

9.    Ajayi OO. Surgery in poverty: Pragmatic options for training and accreditation
in Nigeria. Ninth Faculty of Surgery Lecture. National Postgraduate Medical College
of Nigeria. 27th February 2003. 
10.    Alufohai E Coping with rural surgery: A decade of private rural surgical
practice in Southern Nigeria. 2000  Sam Bookman Publishers, Ibadan, Nigeria. 
11.    OlaOlorun D A, Meier D E and Tarpley J L. Operative management of thyroid
abnormalities in a general medical practice hospital in sub-Saharan African.   Trop
Doct 2000; 30: 221 ­ 223.
12.    Umunna J I Surgeon in the bush. A sugeon’s experience in rural private
practice. Birth Novels Consulting Company, Nigeria, 2006 ISBN 978 076 432 2
13.    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.
14.    Mbindyo P, Blaauw D and English M The role of clinical officers in the Kenyan
health system: a question of perspective Human Resources for Health 2013, 11:32
doi:10.1186/1478-4491-11-32
http://www.human-resources-health.com/content/pdf/1478-4491-11-32.pdf 
15.    Ajayi O O and Adebamowo C A  Surgery in Nigeria. Arch Surg 1999; 134: 206 ­
211.

This guest post was written by Dr Awojobi Oluyombo for presentation at a world summit on rural generalist medicine that took place in Australia last month.