What is your guiding principle?
My guiding principle is to work hard and be focused. Because what I learnt earlier in life is that success is 99% perspiration and 1% inspiration. No matter how bright and brilliant you are, the degree to which you achieve success depends on how hard you work. You don’t simply rely on being brilliant and then you don’t work hard. So my guiding principles are to work very hard and be focused on what I want to do.
What would you describe as your greatest challenge in practice?
There are so many challenges in medical practice in third world countries. Perhaps some of the greatest challenge that one can see is that sometimes you are handicapped in doing certain medical things because of the dearth of facilities and at the end of the day you do what you can within the limit of your ability. That is one of the challenges. Of course another challenge we have is the fact that quite a number of patients do not even know who to see. So by the time a number of patients suffering from neurological conditions see me, they are seeing me too late. Perhaps I would have done better for them if they had seen me much earlier, but because they don’t know until very late. So you sometimes see a patient towards the end, at a time when not too much can be done but you can still do a little. Whereas you would have wished that this patient had come at an earlier time, when some things could still be done.
You have practiced in Europe, North America and Africa (Nigeria). Can you compare the practice of neurology in these places?
I started my practice in Europe because after my post graduate and membership, I worked in the British National Health Service, and I did my neurology at the Institute of Neurology of University of London that is Queens square. The practice of neurology in Europe is the real traditional clinical based practice where you deeply examine the patient and have a well thought out diagnosis you are formulating and then investigate to clarify that diagnosis or to refute it. So you start with a very deep clinical examination based on well trained knowledge that you have been given by any well trained Neurologist. Then after that, you do specific investigations in order to confirm those diagnoses; and it works out well. Now in America, they are technology intensive- in fact there are usually more gadgets and more tools. I practiced in America (University of Virginia) when I was there. One of the things that struck me was that they have so many gadgets and then they will investigate any patient comprehensively. My criticism of that system is that it is excessively expensive because you have to do all manners of investigation for a simple case. So you have to spend so much more. Whereas if you only limit your investigation to what you think you need to clarify after an intense clinical examination and diagnosis, you won’t spend as much. So American medicine is very expensive, because there are so many gadgets and there are over-investigations. They do all sorts of investigation for most trivial neurological conditions. But then both systems are very effective and they have result to see. Now third world country, we have a lot of problems. At the time I was in Virginia in 1998, there were sixteen thousand (16,000) neurologists in the United States of America while we had only seven (7) practicing neurologist in the whole of Nigeria- there was no neurologist at all in the Northern part. This was part of the reason I came back (because there were all sorts of pressure on me to stay back). My colleagues and I have been working very hard to see if we can increase that number. We devised a training programme for the National Postgraduate Medical College which is now used by West African Postgraduate College to train Neurologists. We now have close to seventy (70) in Nigeria- but then you see that Nigeria has the highest number of Neurologist than any other African country including South Africa. It is a third world phenomenon - very little manpower. In fact there are some African countries that don’t even have a neurologist; there are some that have only one or two. So the challenges in the third world country are the dearth of trained personnel. You find out that there are no trained personnel, no neurologist on ground. So because of that, there are so many neurological cases that are not attended to by experts and then the result is usually very bad; and because there are no neurologists on ground, most of the general practitioners are not used to referring cases to neurologist. So a lot of the time they don’t even know what to refer. They don’t know which case a neurologist ought to see. At the end of the day, a lot of the neurological cases I see here are usually self-referral, not even from practitioners- somebody says I know someone who can help you, these looks like a neurological case. Then they come. But I think the position is changing because now that we are having many more neurologists, the general practitioners are now getting aware that there are neurologists on ground so they are referring more and more. So the greatest challenge we have here is so many neurological cases out there are not referred to us to see because many general practitioners do not know we exist.
What are you doing to elevate the practice of Neurology and increase the visibility of Neurologists?
I think that is a challenge we need to address. We have the Nigerian Society of Neurological Sciences. We meet annually. In fact that was one of the discussions we had during the last meeting that we need to increase the visibility of neurologists. To create awareness even among doctors that neurological experts are around and this are cases we are able to help and as a sub-set of the Nigerian Society of Neurological Sciences, we have now formed the Nigerian Stroke Society. I know that I will still encourage them to be more visible. We have had one or two programmes on air, but we want to create awareness that there is Nigerian Stroke Society. That all stroke cases can be managed here locally. There is no difference in managing stroke in Nigeria and managing it in America. If you get to the right place, you will get the same treatment as you will get anywhere in the world. I had told the members that they need to increase awareness among doctors and among patients that stroke can be managed by the neurologist and we now have a number of neurologists who are able to cope with that and once they are told in time; because stroke is like brain attack - you have to handle it immediately, so that you can have better results. Once you get a neurologist informed that this patient collapsed, is unconscious, he has weakness on one side and we think he has a stroke. Can you come and help us to assess? He can go and assess and give the right treatment immediately and you have the good result. Part of that we have demonstrated because I got a research grant from the University of Lagos to look at stroke and we have been able to get the prevalence and incidence of stroke in Nigeria- perhaps the only one in black Africa recently.
Do you feel fulfilled returning to Nigeria having had the opportunity to stay back in the US?
Actually I feel very fulfilled having come back, because normally I had reasoned at that time - I said in staying back in the US, I will only be helping myself and my family. What I would have been earning was very tempting. I will have a lot of money, live in a mansion, and have a very posh life and so on. Then my immediate family will be well off and so on. But then that’s all. I believe that life is worth more than that. People are not living simply for themselves and their family. You must have a wider view of life. I will want to be useful to much more people than my family. So by coming here, even though I am not well off, I am still more satisfied because it has given me an opportunity to be useful to much more people than my family. I have been able to design a programme with my colleagues and start training neurologists and we have trained quite a number. I feel satisfied that I have been able to impact knowledge to some people who are going to be useful to others. I am also satisfied that I am able to treat people who otherwise would have not had access to a neurologist. So that is far more than personal wealth. I am very satisfied even though I don’t have money.
What are your greatest achievements in the field of medicine?
You can look at it from three perspectives: In the field of teaching, my greatest achievement has been to come here to be able to draw up a curriculum along with my colleagues for the training of specialist neurologists in Nigeria and which is also going to be extended to West Africa. Training more neurologists has actually been an achievement I will cherish. Now the other one is being able to save some people who probably would have been written off. People who have highly specialized neurological cases that I have had to save e.g. there was a patient seen by a doctor, the doctor said nothing can be done. He was paralyzed both upper and lower limb and he said the best thing for you to do is to go and meet a spiritualist and pray to God if he can intervene. But his brother who came from abroad said he knows one neurologist and they brought him to me and we admitted him. He had a myelopathy and we got that guy walking and he went back to work. That was a case written off and there are many of such cases. A lot of the time people think nothing can be done and then we did that so that is an achievement. In the field of research, well we have been able to put forth the African perspective. But there is one particular one which was quite globally recognized. In my earlier years, one of the things I found looking at epilepsy was that, we do know that quite a number of people do have seizures when they are watching television or when they have disco light and so on. That is what we call photo-sensitive epilepsy. In my earlier year, I discovered using flicker (you know when we are doing laboratory EEG, we do flashes of light in order to look at the brain wave to see whether it will change it), that in Africans here we didn’t have such photo paroxysmal discharge as we have abroad. All sought of theories came about – whether our pigment was impeding the light and so on. But I had a different perspective that apart from our makeup, there was some protective effect of the environment and I had an opportunity of testing this out when I got a Commonwealth fellowship to train at the Institute of Neurology, Queens square. I had an opportunity of directly comparing the British EEG’s of epileptics and that of Nigerians and be able to prove that the photo paroxysmal discharge was so much lower in Nigerians -0.8%, than in the British- 6%. I was also able to pursue my theory of environmental protection by selecting patients and investigating them in summer and selecting the same group of patients in winter. I was able to find out that in summer they do not have discharge. In winter they did. Which means the bright sunshine was protecting the brain from discharging. From British Meteorological Service, I was able to get sunshine figures throughout the year and then was able to plot it against the paroxysmal discharge and got an inverse relationship. All these publications were well acknowledged and they are quoted in most textbooks of EEG and that also brought about some changes of practice. There was a world meeting on the photo paroxysmal discharge, because in the computer age where you have this visual display units, some children especially abroad now will have to wear special glasses when they have to work on computers in order to protect them from having seizures. My study now showed that we didn’t need that in this part of the world. If you see that they do not give special goggles to children here, it is as result of that study which shows that you require it for children in UK, Japan etc but not in Africa because of the effect of the environment on the brain discharge. Also now, a lot of EEG vendors now say do you really need a photo stimulator. Again, while we have so many spike and wave among the British epileptic patients (22% of patients), in Nigeria I found out that only 5%. That was a confusing one for earlier neurologists who came to Africa, but I said this was an effect of our environment. So these days, it is well established that you don’t wait for spike and wave before you can diagnose. Even if you don’t see it, clinically if it is generalized epilepsy, treat it as such - because you will not see too many, except in children. So these are some of the research achievements that probably may have some bearing on clinical practice.
What is your opinion regarding the issue of residency training in Nigeria?
In America, residency training is a federal concern. The Department of Health and Social Security has a fund which is called Residency Training fund. They know the number of residents they want to train in a particular year and the financial implication. Once you are a resident, you are a post graduate student. The amount to be given to you as a stipend (because you will be working) and the amount for training; courses as well as exams are all built into the training fund. When you come in as a resident, there is no problem. The residents are not employees of the hospital in America. They simply come to train and whatever the emolument and their entitlement is given to the hospital, the hospital just serves as an agent to disburse that money. The hospital runs completely independent of the resident because their budget and everything does not include the resident, because the residency training is a federal concern and they are reimbursed whatever amount they spend on residents. There is a fixed amount of money the residents has to be given as their own emolument while in training. That is how it is done. Here we don’t have such a system. There is the mindset of the resident -because each individual hospital employs and pays them from their budget which shouldn’t be – so they think they are employees of that hospital. They are not, they are trainees. So the moment you start such a policy- National Policy on Residency training- let the resident know that they are on the training from federal government training fund and the disbursement and entitlement is clearly spelt out. So that when you come, the hospital takes you to train you. So you just train and leave and other people will come and train. You are not an employee of the hospital. But right now the system we are running makes each individual hospital employ the resident and the resident thinks they are employees. The hospital uses their local budget. So that is the thing that needs to be done in order to stream line these issues so that in future we have specialist training. When you come in, you know you are a student. You are paid because you are doing some work so that you can do your training without any hardship. By the time you finish as a specialist then you are now trained. But we now have an anomalous situation in this country- some senior residents earn more than junior consultants. By the time you finished training and you now come to be employed as a lecturer, your salary drops. So that is the residency issue.
How can healthcare funding be improved in Nigeria?
What I have seen here is that there is a disjointed healthcare system whereby the private and the public sector are each pulling on their own and even working against each other e.g. Government says I will provide you with free health- I don’t know what that means and then the so called free health is subsidized healthcare. Then the private sector will charge fees because it is not subsidized so each person is working on its own. Government will tax the private sector in order to meet its own obligation. The best approach is to have an integrated health care system whereby every stake holder- both providers whether you are in government or in private sector, you are all having the same stake in providing health care. Your own business is to provide healthcare and it will be well integrated. The only way of having such an integrated healthcare system, is to have a type of healthcare funding that is uniform e.g. the national health insurance was launched in 2007, it has not taken off - only 3% enrolment. Now if you have even 50% enrolment, you can begin to start a real healthcare financing system that will allow for such integration. With such integration, you have the primary care, where the general practitioners will participate. The primary health care worker of the government will participate and all the rest. So if you are a primary care provider whether in government or private, there is fund which is given to you as a capitation for the people enrolled by you. The charges are the business of the insurance not out of pocket payments. Once you are enrolled as an enrollee, then your business is now coping -what are you responsible for? So with such a health care funding system, the government and private sector will now work together in partnership so that they can have an integrated health care system that starts from the primary, secondary and tertiary. Now you don’t know what is primary, you don’t know what is secondary; you don’t know what is tertiary. In this teaching hospital, we see patients in our clinic which ought not to come to us. They ought to be seen by the general practitioners in town. But because there is no clear cut division, they just go anywhere and because it is cheaper to come to LUTH than to see a GP, they will rather come to us. If they are not paying from their pocket and everything was organized, then we would have had an integrated healthcare system. There is also the problem with the Nigerian patient, may be because they pay from their pocket. There is that entitlement mentality that they ought to get health care free. Nobody gets anything free anywhere in the world. You have to pay for what you get and there are several ways of paying e.g. in Canada there is a National health insurance system paid for by tax. When you are working, 1/3 of your money is taxed so that they can provide you with education and health. That money is kept somewhere to provide so you cannot have anything free, it has to be paid for. In America you enroll with HMO and you pay your premium. In the UK, you have national insurance contribution. When I was working there, a sizeable proportion of my salary was taken off for that contribution and it is that contribution that they are using to take care of their free health. So it is not that money will fall from heaven to take care of free health. The fund has to come from somewhere. So the population needs to be educated. Health care funding is a business of everybody either through tax or contribution.
What is your advice to young doctors and medical students?
What I will advise them is to work very hard and to be very focused and also to take their profession as a calling. If you came into medicine for the sole purpose of wanting to enrich yourself, you are in the wrong place. You should go to the wharf and be a clearing and forwarding agent - you will make tons of money (laughs). Patients will look up to you to help them from their suffering and when you do that they will be very grateful. Young doctors who are training should work hard to know as much as possible with the intention of helping as many people as possible. It’s that help that gives you the inner satisfaction that you are doing something. No doctor is going to be rich to be a multimillionaire unless you leave medicine and go into business, but you will have the satisfaction that at least you are helping a number of people.
