SPINE: Fixed in Abuja

Hajiya Zainab walked into my clinic in real pain. I said walked, didn’t I? She actually waddled in and could not wait to sit down. When she sat, she leaned on the left cheek and stretched out the right leg. This was done to ease her pain. She said the pain in the leg travels from the back in shock-like sensations, arriving at her ankle like a succession of locomotive trains.

It turns out she has low back pain and right leg pain. The pain is caused by pressure on the nerves in the lower back due to arthritis. The bones wear out following years of wear and tear. It leads to new bone formation which then encroaches and presses on the nerves. This pressure on the nerves, lead to pain, which shoots down the leg. The leg pain is sometimes called sciatica.

Hajiya Zainab had lumbar canal stenosis. This means there was pressure on nerves in her lower back. The pressure was due to thickening of the ligaments in her back and new bone formations, causing narrowing of the canal through which the nerves supplying her legs go through. She was therefore advised to undergo an operation to remove the pressure and free her nerves. At the time of discharge, following the operation, she practically danced out of the hospital.

Mrs Adisa, an 82-year-old woman presented with a long history of progressive deterioration in her level of function and immobility. She had been wheel chair bound for over 7 years on account of this problem.  This pain in the neck and the various problems with numbness and weakness affecting both arms and legs is caused by arthritis in the neck. The medical term is cervical spondylotic myelopathy: A real pain in the neck. On examination, she had weakness in all muscles in the arms and legs and was unable to stand unaided. Her MRI scan showed advanced arthritis in the neck and she was asked to undergo the operation.

This was carried out and after 5 months of physiotherapy, she was able to walk with the aid of a walking frame. Now, she can at least help herself a little bit and reduce the burden on the family.

Mr Ojukwu is a 65-year-old man married with children. He was previously active and dynamic, a community helper and contributor to many societies in the community. That was before his hands and legs stopped working.

It all started like a joke. Initially, he had some neck pain which the doctor diagnosed as arthritis. Slowly the pain in the neck started shooting down the arm into the fingers. If he moves his neck a certain way, a sharp electric sensation radiates down the centre of his spine. Then, numbness started in the hands and feet. He also complained of an unpleasant ‘drawing sensation’ in his arms and legs.

He required an operation to remove the pressure on the spinal cord. This was performed uneventfully and he went on to make a good recovery. He has become ambulant and able to cater for himself with minimal assistance from the family.

Mr Ode, suffered a neck and spinal cord injury following a road traffic accident. He was paralysed immediately due to damage to his spinal cord. He was recovered from the scene of the accident and transported to hospital in good condition. There he underwent an operation within a few hours, which removed the pressure on his spinal cord. Six weeks later, he was able to walk with the aid of a nurse and using a walking support frame. He has since recovered even more function and back to work.

Medical tourism to other countries

There are some illnesses such as spinal cord injury requiring immediate medical attention that cannot wait for the flight to other countries. The colossal sum of money spent abroad could therefore be used to equip more local hospitals in Nigeria to perform even more in delivering care. Supporting the local hospitals and ensuring that it has both personnel and equipment may be the difference between life and death. Develop your local hospital and help prepare them to be able to help you when it really matters. Anyone proudly strutting off to India and other countries is truly a big fool. That you can afford to travel to other countries is simply not the issue. Many have gone to other countries and return dead despite colossal sums of money spent.

The key issues are that such medical tourism is eroding the fabric of our own health services and further depleting the nation of medical facilities and expertise. It demoralises local medical practitioners and increases the brain drain. It reduces training of medical students, further creating substandard and poorly trained doctors to look after us all in the future. It simply creates a vicious circle we must break free of.

Promoting quality of care

Many cases of effective and efficient management of cases of spine problems abound in Nigeria. Patients do not need to continue to troop out to other countries in search of quality of care. At least for spine, we can now boast of the capability to manage most cases of spine problems to very high standards in Nigeria. There are surgeons in Sokoto, Enugu, Abuja, Lagos and Ibadan making huge strides in providing a quality care. Some are even in our public hospitals. As usual, lack of information on what is available locally impairs access to good care.

Spine: Plans for Nigeria

You need to know that the future is bright, for patients in Abuja with spine problems. This is because there are four trained surgeons in Abuja offering specialised spine care with a full surgical team backup and all the necessary equipment. Neck and back pains can be conveniently managed in Abuja and Abuja is set to be the destination for Nigerians with spine trauma and degenerative diseases.

In fact, there are several big foreign companies such as Medtronic and Covidien now coming to Nigeria to collaborate and support local practitioners. Others such as Infax Nigeria Ltd and Implants International, UK have long been in the game and helping to prop up our failing spine. So, now you know that spine problems should no longer be a reason to travel out of Nigeria. We need the confidence of the people and their trust to move us further forward.

We promise to do our best to make ABUJA the SPINE capital of Nigeria.

Pain... real pain

I will assume that you have suffered pain before. Not emotional pain but real pain. Physical pain that made you cry. Of course, you can remember what happened: no matter how long ago it was.

My pain

For me, I had a most horrible toothache in 1990. The tooth was rotten, infected and wobbly and oh, so painful. It hurt so much that the whole side of my face was red and inflamed. It was as if someone had a blow torch inside my mouth. I took overdoses of the readily available drugs and was even rubbing Paracetamol in my mouth, all to no avail. In the morning, I was the first in the dental clinic, with the singular ambition to get rid of the tooth, by any means necessary. They wanted to save the tooth by performing root canal therapy the next day, but I was not having it. I insisted on an immediate operation and removal of the offending tooth. Yes, I have a gap that meat slips through now, but, believe me, I have no regrets.

The professor’s pain

The professor came to my clinic one fine day. He was in serious pain. His back and both legs were so painful you had to pity him. He had severe arthritis in the spine with pressure on his nerves. He did agree, easily, to an operation on his back. He was in that much pain, he proceeded to have the operation without telling his wife, in case she attempted to persuade him otherwise! He would gladly have subjected himself to an amputation, if it would relieve the pain.

Different strokes

You may think that the professor and I are wimps, who cannot withstand a little pain. But, the pain we had was worse than that of labour. Of course, men also have a higher pain threshold than women. Especially black men, like me: except of course, for my mother in law. She is 80 and suffers from arthritis in the knee. She actually needs a new knee but will not have one, because her pastor says not to. Apparently, she cannot die with an artificial implant in her body. So she bears the pain, daily, every single minute of it. She is one tough cookie and I do not think they make them like that anymore. Sadly though, because of the pain, she does not wish to live long. When you wish her long life, she vehemently refuses to say Amen.

The fact is that everyone copes with pain differently. How are you coping with your pain? How are we managing pain in Nigeria? How should we be managing pain?

How are you coping with your pain?

Understanding your pain and being able to tell the doctor exactly how it is affecting you is important. That means knowing what is happening to your body and how, when, why and where. The way pain is influencing your mood, sleep and life in general is also important for the doctor to understand.

There may be things you can do to make your pain bearable. Talking to family and explaining things to them is important so they can give necessary support. Avoid unnecessary and dangerous drugs, concoctions, processes and procedures, that are unproven and may be harmful is important. Some people have allowed themselves to be scarified in different parts of the body without the pain being solved.

Do some physical activity, if possible, and consider others such as breathing exercises, body scan therapy, physiotherapy, massage, acupuncture, and physical exercises and aerobics therapy. These are known to have many benefits. Apart from improving physical health, other benefits include stress relief, improving sleep and additional benefits from socialising.

How are we managing pain?

Not very well it seems simply from anecdotal experiences. The commoner drugs such as Paracetamol and Ibuprofen, Diclofenac are sometimes misused and abused. There are other drugs such as Amitriptyline, Carbamazepine and Gabapentin which are also not often used to the maximum dose before being substituted. Drug combinations also do not take into consideration, the mode of action and duration of action of the drug. This means that the same types of drugs are used instead of drugs that work through different mechanisms, thus making pain relief more effective. We also have an irrational fear of the pretty strong pain killers due to ‘possible’ complications. The inability to use the drugs in safe mode cause many doctors to avoid them. A patient with terminal cancer was once refused opiates because of the fear of addiction! We do have some drugs but lack easy access to more serious pain killers.

How should we be managing pain in our patients?

It is important to listen to the patient and understand their pain. The history is vital to determine how the pain is affecting their lives and the importance of the pain to them. Pain can be acute or chronic and both can lead to psychological, physical, emotional reactions in the individual. The pain can also be the horrible ‘nociceptive’ pain (the type pain suffered by my mother in law) or the even more horrible ‘neuropathic’ pain (the type of pain suffered by the professor) due to problem with the nerves. Determining which kind of pain it is or whether it is mixed is important. There are different drugs for each type of pain. Before drugs of course, you need to make a firm and solid diagnosis of the underlying cause of the pain. Remove the cause and pain goes away, avoiding the need for drugs!

The way forward

Developing pain clinics and pain specialist services is important. A pain management team is an important group of people that should be in every hospital and are charged with managing serious acute/ chronic pain in patients. Cancer pain, post operative pain and pain without a firm diagnosis are all in the remit of the team. They have special ability and skills in diagnosing and treating pain with multiple arrays of effective therapies. The team is multidisciplinary and involves psychologists and psychotherapists as necessary. The team also has a wide variety of drugs at its disposal.

Their mission is to reduce acute and chronic pain to its least possible level, to restore physical functioning by increasing activity levels and to decrease the psychological impact of pain on the person.

Ask for the pain team in your local hospital.

Dinner with the devils in the health sector

There are two facts you need to know.

One

There are about 36 neurosurgeons in Nigeria and perhaps on average, one neurosurgeon for 5 million Nigerians. There are 4 neurosurgeons in Abuja (FCT) and 4 in Lagos. There are about 6 in Ibadan and 5 in Enugu. It is important to note that most of the neurosurgeons are in the big cities. This means that the vast majority of Nigerians especially in the rural areas have no access to neurological services.

Two

When I pray, I pray for good health, long life and prosperity. I do not pray for money. Money and material wealth are important for daily living but do not rule my life. The most important ingredient for a great life is actually abundance of good health. For instance, no amount of money is enough to treat stroke, spinal cord injury or cancer. Better therefore, to pray not to have any of these diseases! Better than just praying, is to actually, actively prevent them from happening to you!!

Sorry, I digressed

If there are 36 neurosurgeons in Nigeria and there are 36 states in the Federation; it would be great if each state had a neurosurgeon and full facility to offer neurological services: this ensures a nationwide cover. Then, access would be increased and these centres could build and develop for the future, increasing the training and yield of neurosurgeons for the country.

Each centre would need a fully functioning emergency admission facility, ward, staff, equipped theatre with necessary consumables and possibly an intensive care unit. The hospitals or at least the local area should also have capability to investigate neurological problems. This means access to a computer tomography (CT scan), magnetic resonance imaging (MRI scan) and x-rays facilities as necessary. The manpower requirements are vital as the staff need special training and orientation in neurology. Neurological diseases such as stroke and head injury require urgent management and often cannot wait till the next morning. Someone may die or be severely disabled as a result. You waste time, you lose brain is the common adage. You need staff to be on their toes all the time.

Armed with the desire to help and the foregoing information, how can the states without neurological services, ‘acquire’ their own neurosurgeon and thus, develop the practice as highlighted above?

Contact with the devil

You take a plan, proposal or an even just an idea to a director, commissioner, minister or a Governor. If you are lucky, they might reject it outright and be done with it. If not, they might reject it and then surreptitiously rebrand it, and implement it as their own creation. They may (very, very rarely) adopt the plan and move swiftly to implementation. Or of course, they may sit down with you and try to work out the sharing formula as you implement the program. That is crunch time.

Dinner with the devil

Our people in positions of authority appear to be ‘instinctively corrupt’ and do not seem to have the interest of Nigerians at heart. There is apparently systematic corruption inbuilt to fail Nigeria at every level. Many people now have a medical condition called ‘what is in it for me syndrome’. Everything must lead to some immediate monetary value for them and they seek all opportunities to defraud the treasury.

So, acquiring a neurosurgeon and setting up a neurological service, is immediately seen as a veritable means of acquiring wealth. Okay, so now they are wringing their hands and already calculating how much money might drop from this new venture to bring a practice of neurosurgery into being. In my short time since returning back to Nigeria, I have become aware of Chief Medical Directors who (when asked to buy equipments) procure cheap, refurbished, degraded equipment at huge expense and force the staff to accept and use them. They buy through their cronies or conniving middlemen (and never directly from the manufacturer!) in return for a share of the cost. So what if the equipment fails to work? It means the contract has to be re-awarded: more money to share!

At the expense of fellow Nigerians

There is a state in Nigeria which has employed foreign doctors as specialists in its hospitals. These people are paid in dollars for providing substandard care for the people. But, of course, some official is benefitting from the misery of the people. Take also the case of a hospital in Abuja. It was recently reported that the hospital is run by a business woman without any executive oversight by a Nigerian medical doctor. The doctors employed there are said to be ‘juniors’ and not the fully trained specialists they claim to be. They were also apparently hurriedly registered (under duress) by the Medical and Dental Council of Nigeria. Even though tales abound about this hospital, it is still in operation. There are Nigerian officials benefiting from the largesse of the hospital and therefore offering it protection. At the expense of the people!

Foreign fodder

Many Nigerian neurosurgeons and other doctors in the Diaspora are eager to return home to help. The few that have made the effort have been frustrated at the dinner table of the devil. The returning Nigerian doctors are not made welcome. Many are treated as foreign fodder, used and abused. It starts with the pressure from home based players in position of power who feel threatened and insecure in the face of new knowledge. There have been numerous reports of rejections and outright hostility from home based doctors. I even met a doctor whose life was threatened by another local doctor for thinking he can come back home and compete for patients. One doctor was reportedly attacked by paid assassins. Should we not be creating a favourable environment for these trained doctors to come in and contribute to the development of the health sector? Which we all agree is in shambles?

Coming back home creates more jobs for the average Nigerian. The doctors come back with skills and funds to open new practices, explore new ideas and new treatments. They can also increase the employment of nurses and other allied staff, thereby creating more jobs for youths. But to work in the public sector means dining with the devil. Yet, it also means some improved access to enhanced healthcare for the majority of Nigerians. The Diaspora can create more food at the table of more Nigerians.

Dessert at the devil’s table

The quandary is simple: To dine with the devil, lose your morality and succumb to the corruption: if it leads to the provision of the aforementioned services or to eschew corruption in all its ramifications and therefore, we continue as we were? Or is there a middle ground? Can you lose your morality, perhaps for a little while, in order to save more people? This means just eating dessert with the devil and skipping the main meal. Perhaps this is a bit more palatable and easier to digest?

Or perhaps do what the Indians have done, by opening mega private hospitals that provide cheap care for the poor and charge expensively, the rich, who end up subsidising health care. It also might open up the vista for medical tourism to Nigeria. Is this therefore the answer? That, the neurosurgeons, can open up private neurosurgical hospitals in part partnership with the public sector to provide services for the people. Of course, I have used neurosurgery for my analogy, but this could easily apply to other services and specialists that are sorely needed in Nigeria.

Menus please!

Journal Of Neurosurgery Article

Journal of Neurosurgery
Sep 2012 / Vol. 117 / No. 3 / Pages 599-603

Article
Increased population density of neurosurgeons associated with decreased risk of death from motor vehicle accidents in the United States
Clinical article
Abstract
Object
Motor vehicle accidents (MVAs) are a leading cause of death and disability in young people. Given that a major cause of death from MVAs is traumatic brain injury, and neurosurgeons hold special expertise in this area relative to other members of a trauma team, the authors hypothesized that neurosurgeon population density would be related to reduced mortality from MVAs across US counties.
Methods
The Area Resource File (2009–2010), a national health resource information database, was retrospectively analyzed. The primary outcome variable was the 3-year (2004–2006) average in MVA deaths per million population for each county. The primary independent variable was the density of neurosurgeons per million population in the year 2006. Multiple regression analysis was performed, adjusting for population density of general practitioners, urbanicity of the county, and socioeconomic status of the county.
Results
The median number of annual MVA deaths per million population, in the 3141 counties analyzed, was 226 (interquartile range [IQR] 151–323). The median number of neurosurgeons per million population was 0 (IQR 0–0), while the median number of general practitioners per million population was 274 (IQR 175–410). Using an unadjusted analysis, each increase of 1 neurosurgeon per million population was associated with 1.90 fewer MVA deaths per million population (p < 0.001). On multivariate adjusted analysis, each increase of 1 neurosurgeon per million population was associated with 1.01 fewer MVA deaths per million population (p < 0.001), with a respective decrease in MVA deaths of 0.03 per million population for an increase in 1 general practitioner (p = 0.007). Rural location, persistent poverty, and low educational level were all associated with significant increases in the rate of MVA deaths.
Conclusions
A higher population density of neurosurgeons is associated with a significant reduction in deaths from MVAs, a major cause of death nationally. This suggests that the availability of local neurosurgeons is an important factor in the overall likelihood of survival from an MVA, and therefore indicates the importance of promoting neurosurgical education and practice throughout the country.

MEDICAL TOURISM... WHO CARES?

As published in the Blueprint Newspaper on Thursday 23rd August 2012

 Nigerians who cannot afford medical tourism

In the news recently (Sunday Trust, 19th August), Ibrahim Mohammed, a patient, was refused carriage by airlines in his quest to travel abroad for treatment. Ostensibly, because he was spinal cord injured from a road traffic accident. He had been lying, paralysed, in a hospital bed in Kano for about a month. He was eventually treated at Primus Hospital in Abuja…. by an Indian doctor. Both the patient and the doctor are apparently happy.

Who cares?

We should care about the real story behind this story but as always, we do not have the full facts. The story says that the patient works for the Kano State Government and money was not a problem. The National Orthopaedic Hospital, Dala, is one of those labelled “centres of excellence” and one place he should have found succour. Why could he not have been offered treatment by the neurosurgeons and numerous orthopaedic surgeons in the North? Did he refuse treatment locally? Why was he desperate to fly out of the country for treatment?

Let us digress

It is an inalienable right of Nigerians to choose where they go for medical treatment. Patients have a choice and the right to seek the best medical treatment for themselves. This happen in all communities and the need to preserve life and limb means patients and their relatives will gravitate to the best medical care available. We (health care practitioners) could and should be involved in directing them to the appropriate places where they will get good care. One of the key components of care is confidence in your health care practitioner. If you are happy and feel you will get better, most times, you will. After all, we care and God heals. Should they decide to go outside the country, for whatever reason, we should be able to provide post medical tourism care for them. After all, they cannot afford to stay abroad forever.

Home support

In truth, the poor health care delivery in Nigeria and poor medical advice have contributed to the mass movement of our patients to ‘safer’ shores. It is not enough to say patients should not go to India, Egypt or elsewhere, we must give them a good reason not to go. The best reason is good medical practice and effective communication. More importantly, doctors must appreciate their professional and personal skill level and limitations in practice. If you cannot treat the patient, know who can, learn to refer early to preserve the life and limb of your patient. Working together and better communication between professionals are the prerequisites for good quality of care.

Minimum standards

Dr Azodoh, Consultant Urologist with Chivar Clinics, Abuja once said that we need to provide a better standard of care for Nigerians. At the minimum, hospitals must be equipped with the basics to ensure life and prevent death. For example, the presence of simple oxygen and monitoring equipment for use by the patient can actually make the difference between life and death in some situations. We must be able to provide a satisfactory level of care for patients in this country. It therefore means that everyone must be hands on deck to improve standard of care. Medical practice in Nigeria must return to the good old days when excellence of practice was the by word. Running away at the time of need does not help.

Health Care Practitioners

Health care practitioners are educated people who have left health policy decisions to be made by uneducated and unqualified people. A lot of our medical infrastructure and respect has been eroded because of this oversight. We have a responsibility of guiding and influencing policy change at all levels – making top government functionaries see the bigger picture of these issues. We have the potential and the capacity to do this and that is what we should strive to do. We dare say that the responsibility to bring back the faith and trust by the Nigerian populace in our healthcare systems in the long term rest with all of us collectively. This faith is being restored by the formation of the Health Care Practitioners Association of Nigeria (HC-PAN). The association is a collective umbrella body of all health care practitioners and is in prime position to provide a solid basis for improved health care delivery systems in Nigeria.

Medical tourism is big business

India’s National Health Policy declares that treatment of foreign patients is legally an “export” and deemed “eligible for all fiscal incentives extended to export earnings.” Government and private sector studies in India estimate that medical tourism could bring between $1 billion and $2 billion USD into the country by 2012. Specifically, it has been reported that India earns about $260 million USD from medical tourism from Nigeria alone. So, this is big business for India and they are actively pushing this activity and generating huge revenue from Nigeria. This is truly appalling and we are losing significant revenue to India and other countries. Instead, we should encourage inward medical tourism- into Nigeria. There is no reason why we should not be earning this money for Nigeria instead. This is money that could be used, potentially, to develop our crumbling health infrastructure.

Support your local

The colossal sum of money spent abroad could be used to equip many local hospitals in Nigeria to provide equitable standard of facilities and care for all Nigerians. Sadly, Nigerians, and many politicians and government officials do not support their local hospitals both morally and financially. They forget that some illnesses are so acute requiring immediate medical attention that cannot wait for the flight to other countries. Supporting the local hospital and ensuring that it has both personnel and equipment may be the difference between life and death. Anyone proudly strutting off to India and other countries is truly a big fool. Develop your local hospital and help prepare them to be able to help you when it really matters. That you can afford to travel to other countries is simply not the issue. Many have gone to other countries and return dead despite colossal sums of money spent.

Demoralising local doctors

One other fact is that medical tourism is further demoralising local doctors and sapping the little energy and interest remaining. This is very important and should be of concern to every sane Nigerian. We recognise the fact that over time, Nigerian doctors and hospitals have lost the trust and respect of patients. Rather than seeing this as a reason to seek medical attention elsewhere, this should be a call and pressure applied to the government to optimise and improve our facilities and expertise. Patients are best served by medical treatment provided close to where they live; particularly in emergencies.

The key issues are that such medical tourism is eroding the fabric of our own health services and further depleting the nation of medical facilities and expertise. It demoralises local medical practitioners and increases the brain drain. It reduces training of medical students, further creating substandard and poorly trained doctors to look after us all in the future.

It simply creates a vicious circle we must break free of.

SEX STUPID?

Peter Ebeigbe recently published results of his study into the ‘knowledge and use of contraception by rural in-school adolescents in Delta State’. The article appeared in the recent edition of the Nigerian Journal of General Practice (March 2012). It makes disturbing reading and I believe every adult especially teachers and general practitioners should read it. He wanted to find out the knowledge and use of contraception by adolescents in randomly selected rural secondary schools. He distributed questionnaires to 233 children, and found that only about half had had any information about how to prevent pregnancies. The information was from doctors and nurses in 17.2%, school teachers in 16.7% and a family member (relatives/elder sister) in 11.2%.  My first question is: what is the input from fathers and mothers? Are we shirking our responsibilities?

In the article, Dr Ebeigbe further noted that about 65% had had sex at age 15 years. But, perhaps more worrying is that only 31% (31 in 100) used a condom consistently, 39% practiced coitus interruptus while 25% relied on ‘washing the private parts’ to prevent pregnancies and diseases! The high level of ignorance highlighted by this study is incredible, especially in this age of the internet and wider availability of information. The second question I have is this: What is the policy on sexual education in our schools and when is such education delivered to the children?

Sex Stupidity

Exposure to sex and early sexual debut in teenagers is a risky behaviour and counter measures must tackle this aggressively. In one report, a substantial proportion of adolescents reported not being able to communicate with their parents about HIV/AIDS, abstinence, or condoms. There is very low level of sexual communication between children and parents and an uncomfortable silence is common across all socio-demographic subgroups. Previous studies suggest that mothers can help adolescents make responsible sexual decisions by talking with them about sexual health.

Yet, it is not clear how and when mothers make decisions about talking with their adolescents about sex. Studies are needed to determine how mothers make decisions about talking with their adolescents about sex, as well as to examine to what extent and in what instances mothers can reduce their adolescents' sexual risk behaviour by providing comprehensive, developmentally appropriate sex education well before adolescents are likely to debut. Information must be provided to children early emphasizing the importance of abstinence and delay in sexual experimentation. With the booming spread of HIV throughout the World, a sex education program in schools is urgent. The government has a duty to our future generations.

Abstinence and remaining a virgin must be promoted as desirable societal qualities. American Academy of Pediatrics recommends counselling teenage children on sexual behaviour and postponing sexual activity. Educated parents are still resistant to impart healthy knowledge and practice of sex with their adolescent children. Most teenagers use their peer groups as the sole responsible guides: to inform them about their sexuality and most of the time, may be driven to the wrong practices. As AIDS is spreading like fire in every part of the World, educating teenagers is an urgent need before HIV makes its way through among the innocent teen children. Parents cannot and should not be ashamed to discuss sexual matters with their children. Do not leave them sex stupid!

Condom use by all

Despite recent reports that there is increasing condom use, generally resistance to condom use is still high. There are studies, carried out between 1990-2004, showing that young people assess a potential partner’s disease risk, and the need for a condom, by their appearance and how well they know them socially. Factors inhibiting condom use and exploring issues of responsibility for safe sex practices to prevent infection must be discussed openly. We need to reinforce the thoughts that safe sex practices (specifically condom use) should be everybody's responsibility. It is not the 'other' persons’ responsibility. Each individual must be equipped with condoms and so eliminate the pressure associated with decisions whether to proceed with unsafe sex or not. With the real risk of such dangerous diseases as Hepatitis and HIV/AIDS on the horizon, you cannot afford to be complacent. It is wise to have a stack of condoms at home and in your wallet. It is foolish not to have one if there is even a remote possibility you might be having sex.

Sex is a dangerous game

With the exception of the few who engage in sexual marathons, most people agree that sex lasts on average about 5 minutes. Thereafter, the effect can last a lifetime with pleasure, pain or death to follow. In this regard, the pleasure could last for a short time afterwards, then followed by more pleasure on the background of a happy relationship, or be trailed by pain in unrequited love and the many tragedies related to unhappy liaisons. Or sex can be followed by tragedy, misery and even death. The question remains: Has attitudes to sex changed over the past decade? Do people now realise that sex is not just a passive pastime and more importantly, that ‘sex is a dangerous game’.  This of course, since the 80’s, is mostly because of the scourge of HIV and AIDS. HIV/AIDS has grown to become the biggest epidemic in modern history.

The people who should know

In 1997, at the Davos International Economic Forum, Nelson Mandela stated that "the poor, the vulnerable, the unschooled, the socially marginalized, the women, and the children, are the sectors of society which bear the burden of AIDS". Nearly a decade later, that statement still holds true, especially in Mr. Mandela's home country, South Africa.  In the same country, former South Africa health minister, Manto Tshabalala-Msimang, nicknamed, Dr Beetroot, was ridiculed for promoting garlic and beetroot rather than antiretroviral drugs for treating the HIV/AIDS. The tragedy was that she managed to persuade her government to apply these beliefs in national health policy, with disastrous consequences. South African politicians, including President Thabo Mbeki bought into such ‘lunatic thoughts’ and tens of thousands of South Africans lost their lives because of their ridiculous policies on HIV/AIDS.

You have heard, of course, seemingly sane people promoting herbal cures of HIV/AIDS in Nigeria. Radio and Television stations, because of the revenue, carry advertising of untested and possibly dangerous remedies. How many people are they killing, inadvertently?

There are huge gaps in the HIV/AIDS knowledge of the people in Nigeria especially the marginalised, rural and uneducated. It is often the fact that many hear of HIV/AIDS after the ‘horse has bolted from the stable’. Peoples’ sexual behaviours are affected by the environment they live in and influenced by thoughts and actions of peers and other people.

Accepted behaviour is reinforced within the community and is difficult to change by external interests or even health personnel. But we must try. Doctors, nurses, the educated and those in government should have up to date knowledge of best sexual health practices and the risks inherent in unsafe sexual practices.

No street cred

The point to note is that HIV/AIDS has no street credibility. You cannot be proud to have AIDS. It is not like cancer which is acceptable in the community and which can even be ascribed to a spiritual attack. It is currently not a disease to be proud of, despite the number of high profile cases in the news. HIV/AIDS is not fashionable and is regardless of how you contracted the disease. It could be you were infected by your loved one, or via a needle stick injury in a hospital or blood transfusion. It may even be after your very first sexual experience. It does not matter. Nobody truly cares about the history and how many people are you going to tell? As always, prevention is better than cure.

Sex is a dangerous game: it has always been, but more so now than ever.

Spinal cord injury: What you need to know

As Published in Blueprint Newspaper Thursday 19th July 2012 

I find it rather amusing and unbelievable that anyone can have a road traffic collision on Sunday afternoon in Abuja. I mean the roads are great to drive on and often quiet with little traffic. So, I am always amazed that people still have head on collisions and fatal crashes on a day of rest! Monumentally stupid to be rushing around on a lazy Sunday!

The fact is that driving skills are abysmal and many people seem to lose their heads once behind the steering wheel. Now, with such accidents, some people also lose their necks. Spinal cord injury is all too common in Nigeria, that I am considering going around with a hard neck collar: so I can apply it on the next accident victim.

Prevention is cheaper

I got into a taxi cab to travel a short distance. I usually sit in front and with the seat belt fastened. On this day, the driver said, ‘Oga, no need for seat belt, na short distance we dey go’. I looked at him and asked him whether he thought I trusted his driving. He laughed, nodded his head in understanding and promptly put on his own seat belt. When I seat in front like this, I am also driving with the driver, watching the road and cautioning about care on the road and speed. It is the least you should do.

You know, in the past, farmers and palm wine tapers, falling off trees, were the people who sustained spinal injuries. Nowadays, road traffic accidents account for the majority. Many patients have been involved in accidents where the vehicle somersaults several times. The injuries occur often at the time of the accident or subsequently during extrication or transfer to hospital. Most patients present with partial or complete paralysis of the arms or legs or both. This includes loss of sexual function and loss of the ability to urinate or pass stool normally. This is because the spinal cord carries all the nerves that supply movement and sensation to the rest of the body. If the cord is severely damaged, the paralysis may be permanent.

A costly business

In the past, most patients with neck injuries in Nigeria were managed conservatively (without operation). This was because of the paucity of experts trained in managing such injuries, lack of specialised equipment and of course the cost of treatment. Even then, the cost of not operating is significant. The cost in managing a paralysed person includes the hospital bills, costs of a carer to look after the person, loss of income and long term rehabilitation costs. This could easily run into millions of Naira. There are also significant material and emotional costs.

Helpers do more harm

Ideally, treatment should start at the site of trauma. Safe and careful extrication, safe transportation and immobilisation in hard neck collar are crucial. It is known that following neck trauma, stabilization using a hard collar reduces movement of the neck. These patients cannot and should not be moved without adequate protection and care. I cringe when I see members of the public attending an accident and pulling the victim without due care. Please just call 122 to summon the Federal Road Safety Corp.

Initial care

Spinal cord injury with paralysis is often associated with lifetime morbidity, so early active management is crucial. The initial care of patients with acute injury to the neck (cervical spine) is of paramount importance. Function of the nerve and spinal cord can be adversely affected by excessive motion of the unstable spine.

Diagnosis

Early diagnostic and clinical evaluations are important in determining the severity of the injury and making plans for subsequent management. Timely and appropriate imaging studies using x-rays, CT and MRI scans are essential to the cervical spine evaluation. Hospitals must be able to offer early neurological evaluation, investigation, diagnosis and surgical management to the majority of patients.

Management, manpower and resources

Because of the inadequacies of many of our hospitals and lack of equipments to perform the operations and rehabilitation, it has become very expensive to treat patients with this kind of condition. This is why many patients with spine problems get abandoned by their relatives because they could not afford the cost of treatment. Some families also take their patients home, where many of them later die.

Rehabilitation?

Prolonged survival has resulted from better understanding of the effects of spinal cord injury. All over the world, spinal injury centers have done much to increase the survival of and quality of life of cord injured patients. Rehabilitation is also very important whether the patient has been operated or not. The importance of the role of post-injury rehabilitation cannot be over emphasised.

No rehabilitation centres!

There is need to congregate these patients in spinal rehabilitation centres where dedicated experts and facilities exist for improving the outcome of treatment through physical and mental rehabilitation. The establishment of rehabilitation centres would go a long way in improving the social rehabilitation and survival of the patients. Some of my patients travelled abroad for rehabilitation. This cost on average about N20 million for 3 months of rehab. I am yet to see the benefit and that money is better spent creating similar units here in Nigeria.

Know the facts

The high morbidity associated with spinal cord injury could be reduced through public enlightenment on road safety measures and personal awareness. Wear a seat belt, drive carefully and be cautious, wary of other road users. Do not let anyone drive you crazily (this includes public and private vehicles).You cannot be too careful. You cannot afford to have a spinal cord injury. It’s your neck so protect it by using your head!

Seriously, we need to establish or refurbish spinal and trauma centres that are equipped to function. Improved outcomes can be achieved with a careful approach and multidisciplinary integrated care including improvements in intensive care and effective rehabilitation centres.

Protect children

Children are transported in pretty dangerous manners in cars on our roads. Many times, I see children unrestrained in cars and this is not right. There must a law against this and it must be actively enforced. This is child abuse and should be stopped. It is even worse when you see that the driver (mom or dad) is wearing a seat belt!

BASIC LIFE SUPPORT

Recently, I asked Chief Medical Directors, “Can your hospital save your life?” Do you have staff trained in the basic life support skills: such that if YOU are taken to your own hospital, they will give the best and necessary care, to save your life? This is an important question and hopefully will push CMD’s to review their hospital’s delivery of vital life saving services in emergencies. Same goes for all organizations involved in medical care and resuscitation. If needed, there is a course on basic life support and trauma care coming up in Abuja next week.   

This provides an opportunity to equip yourself and staff for life. Please call me for more information.