Introduction

In March I travelled to the south east of Nigeria to join an initiative of the Nigeria Health Care Project, a charity run under the auspices of the Methodist Church. Opened in August 2002, The Royal Cross Methodist Hospital has a total of 36 beds and is staffed by a lone Dutch doctor with considerable experience of tropical medicine, and 12 other staff members, with varying degrees of training and responsibility. Up to the point that it opened, the surrounding community – incorporating a population of around 56,000 – was visited by a doctor around once every six months. Though still in its formative stages, the hospital already offers a wide range of services including ophthalmology, surgery, paediatrics and maternity care to the people of these communities.

Nigeria suffered considerably as a result of years of military dictatorship (in 42 years of independence there have been just 12 years of democratic government), particularly with regard to the basic infrastructure of the country. Although our own health service has been the subject of immense scrutiny in recent years, in Nigeria there simply is no NHS; the sick are forced to rely on often scanty medical knowledge and the sporadic dispensation of drugs. Add to this the HIV/AIDS crisis that is crippling the developing world, and one begins to appreciate the enormity of the challenge faced by those who provide health care.

The Challenge of Working in Isolation

When the importance of multi-agency working has been at the very core of your medical training, and having an appreciation of the roles of other health care professionals is key to effective health care delivery, “flying solo” brings with it a number of new demands. In the UK, the challenge is very much about knowing where the resources are in order to tap them; in Nigeria the challenge is accepting that there are no resources to be tapped. This brings with it absolute responsibility, particularly for the sole Medical Officer of a rural hospital. Add to this the complication of the need for an appreciation of cultures and rituals of a society in which you were not brought up, and the task becomes appreciably more arduous. My supervisor had an abundance of experience of practising medicine in Nigeria, and such adaptations had become almost second nature to him. This being my first visit to the developing world, the demand for cultural adaptation was considerable, even without the co-existent demands of applying my limited medical knowledge and experience to the situation. The lack of an established health care system or the resources of Western hospitals - so envied in this part of the world - compounded the difficulties.

There are a number of situations that remind me of the difficulties I encountered. Transport is very limited within Nigeria, and the lack of running water in homes make the ability to walk to the nearest stream or bore-hole of paramount importance to survival. Place into this situation a woman with osteoarthritis affecting her hips and knees, and trying to advise her that she should no longer carrying anything heavy either on her head, or in her arms. Because of your white skin and the status of being a doctor, she will not question your advice, but is only too aware of how impossible it is for her to adhere to such advice. Furthermore, there were no other agencies to which she could be referred in order to try and improve her situation; no occupational therapists to provide her with aids, and no social services to assist her in the tasks of daily living. Although we could give her a reason for the pain and stiffness she was experiencing, there was little else we could do. This was certainly not an isolated occurrence and was immensely frustrating.

The Challenge of Resources

From foodstuffs to electricity, water to transport, the majority of the Nigerian population have limited access to few resources, and those which can be accessed are often of dubious quality. It is not that Nigeria is without the ability to provide its people with these necessities, but rather that the huge gap between rich and poor is such that cost-cutting at the expense of quality is very much a way of life. The situation is not improved any for those with the responsibility of providing health care. Unfortunately, it appears that the only way to practice medicine is to accept and expect that the resources available to you are likely to fail you, to be surprised when they don't, and to improvise when they do. This can make the practice of medicine immensely stressful and frustrating.

The Challenge of Poverty

Although there was a huge demand for the services offered by the hospital, managing patients involved a precarious balancing act between the most effective treatment strategies available, and the limitations of the patient's own resources. In the UK we are educated in the need for an awareness of the financial and economic implications of our treatment plans for the health service. When an individual who struggles even to feed and clothe themselves and their family must meet the price of your choices, such considerations bring with them a different kind of responsibility. What is more, when providing treatment that is beyond the resources of the patient concerned renders them reluctant to return to the hospital in the future, the construction of a management plan demands the strictest prioritisation.

The Stigma of HIV

It would be impossible to report on the practice of medicine in sub-Saharan Africa without making some reference to the devastating impact of HIV. One of the major challenges in the HIV campaign is the conflict with ignorance. Sex continues to be a taboo subject in this country, where there are no formal health and sex education programmes. Indeed, such education is often thought to be an encouragement for young people to have sex. In the close vicinity of my accommodation there was a boarding school owned by the Methodist Church. Whilst there I was asked by the Methodist Bishop if I would provide the children with health and sex education. He was concerned by reports that many of the girls who began their menstrual periods had thought that they were dying. He had also just returned from an HIV conference in America, and was keen for the prevention strategies to be put into place in the diocese. It was thought that as I was white, female and training to be a doctor, that I would be a suitable person to talk to both girls and boys, and that they would take heed of what I was saying. In addition to this (as I discovered) many of the staff at the school simply didn't have any knowledge to impart with regard to sex and puberty and, more worryingly, they had been misinforming students when faced with queries. Consequently, I provided both staff and pupils with basic health and sex education, including information about the risks, routes and consequences of HIV infection. It was incredibly well received, and in many ways I felt that this was the best contribution I made during my time there. Although the HIV situation is exacerbatedby the lack of treatment and counselling services, it is the lack of education that is the real demon in the situation. It is difficult to see a way forward from this in a country that is so divided on so many issues, and one where talking about sex is so culturally unacceptable.

The Challenge of Perception

Despite the experience of living in two of the most cosmopolitan cities in the UK (aside from attending university in Leicester, I was brought up in Bradford where I was an ethnic minority in my primary school) nothing could have prepared for the reaction evoked by my skin colour. One of the saddest things about my experience was the realisation that, after 42 years of 'independence', most Nigerians still feel so dependent on the “onye ocha” whose white skin opens so many doors that are closed to them. The fact that I would, in the future, have the power and status that t hey associate with being a doctor only served to exacerbate the situation. Indeed, far from opening doors, there were distinct occasions when my skin colour proved to be the most impenetrable barrier to my assisting in the work there. It is difficult to truly connect with people when they perceive you to be so much better than they are. Nonetheless, it is true that my white skin also afforded me many privileges and opportunities that would otherwise have been unavailable. It is hard to say which of these predicaments provided me with the greatest challenge...

Conclusion

Nigeria challenged the core of my being and I must confess to being left wondering how anyone in the world manages to survive without faith. It seems to me that the material wealth and resources of the Western world allow us to forget how fragile life truly is. For the people of Nigeria, this fragility is a truth that is universally acknowledged and accepted.

Throughout my stay in Nigeria I was continually thanked for the sacrifices I had made in leaving the comfort of the UK to go to help the Nigerian people. Truth be told, I learned more from these remarkable people than I could ever have hoped to have given to them. I was reminded of the true foundations of life; the necessity for and the joy reaped from investing yourself in a life of service, both to others and to God; and the need to live life to the full. Nigeria really got 'under my skin'. I sincerely hope that this is a story to be continued...