One Emergency Away

You are, as Dr. Nana puts it, one medical emergency away from bankruptcy in Nigeria. Jii sits with Dr. Nana Abadri, a doctor who began her housemanship the same week the country locked down, to look at the system most of us only meet when something has already gone wrong.

They move from clinics and teaching hospitals to the quiet belief that going to hospital means not coming back; from malaria that kills because treatment started too late to why we minimise our own symptoms until we cannot. Underneath it sits the question that runs through this show: who can actually afford to be well? No drug, diagnosis, or prescription is offered here. It is a conversation about how we live with our health.

How We Live is an Inskriba production. The conversation continues in writing at inskriba.com.

Jii: Welcome to Inskriba Conversations. This is an intro to another sector, the health sector, and I have a doctor here. We will jump straight into it. But first and foremost, welcome to Inskriba Conversations. Please introduce yourself.

Dr. Nana: Thank you. My name is Nana Abdulkadir and I am referred to as Doctor Nana. I am a medical doctor. I graduated in 2019, and I have been practising since 2020. [inaudible] I currently practise in [inaudible].

Jii: So you started practising during COVID. Did it have an effect? Obviously it did, but how?

Dr. Nana: Yes, definitely. The way it works in Nigeria, after medical school you do housemanship. I could not go straight to housemanship because I am foreign trained. So I came back in 2019 and I had to write my licensing exams. I wrote my licensing exams in 2019, I was inducted in 2020, and then I started practising. I resumed for my housemanship in March, and I kid you not, the week I resumed was the week we went into lockdown. Shortly after the day I resumed. It was actually crazy.

Dr. Nana: My housemanship was at UITH in Ilorin. And Ilorin took the lockdown really seriously. Honestly, I am recommending them. They were one of the first states to go into lockdown, and they were very, very strict about movement and all that. I think it really helped them.

Dr. Nana: As for the way COVID affected my housemanship: by the end of it, housemanship ended in 2021, things had more or less gone back to normal. But when I started, there were a lot of things we used to do that we could not do anymore. Daily rounds, for example. Just a brief little sprinkle: for housemanship you rotate through four major departments. I started with surgery, then medicine. Usually all the doctors used to come every day, see all their patients, and surgery days were assigned to certain teams.

Dr. Nana: But because of COVID we were trying to minimise contact with patients. So elective surgeries were practically cancelled. There were so many surgeries that could be pushed back. Of course emergency surgeries would still be done, but so many surgeries were pushed back. A lot of people were not on admission. At that point it was basically just emergency cases we were attending to. So you could not really do [inaudible]. It was very rigidly regimented.

Dr. Nana: We did not go to work as frequently as we should have. They made timetables, so you would maybe go to work today and then next be at work three days later. The whole point of that was to minimise contact with patients, just in case. The irony was that because of this, basically everybody saw everybody's patient. Let us say Dr. A has to see Dr. B's patient, because of the way the rota was we now made it that only Dr. A will be on duty on this day and Dr. A will see everybody's patients. And then the next time Dr. A is around is in three days. That was what we were doing.

Dr. Nana: There was actually a patient who tested positive for COVID, and because of the way we had made the rota, all of us were exposed to her at the end of the day. Because all of us had seen her. It was crazy actually.

Dr. Nana: It also affected clinics. There were no clinics, which sucked. No clinics at all. Any outpatient thing we did was strictly on an emergency basis. That was actually a crazy era. Everyone was wearing face masks, of course, so I did not know what a lot of my co-workers actually looked like.

Jii: That is interesting. And this is one of the reasons we are looking at the health sector, because it is important as a system in the daily lives of Nigerians, Africans, anywhere in fact. This is part of Inskriba Conversations. And just a disclaimer: we are not giving out healthcare advice, we are not giving you a prescription, we are not advertising any drug or medicine. We are just having a conversation about health. But you said clinics. What is the difference between a clinic and a hospital?

Dr. Nana: A clinic is what most people come for when they are coming to the hospital. A clinic is outpatient. You basically walk into the hospital, you have your complaint, you have your consultation with the doctor, your medications are prescribed, your tests ordered. That is the concept of a clinic. It is just on an outpatient basis. The hospital is the rest of it, where when a patient needs to be admitted, they are no longer in the clinic, they are going to be admitted into the hospital.

Jii: So every hospital has a clinic.

Dr. Nana: More or less, yeah.

Jii: That is again some of the questions we are trying to understand, especially for Nigerians, how they interact with everything that has to do with their health. But before we move on, you said you did not study in Nigeria. Do you want to give us insight into how that journey was?

Dr. Nana: Yes, I studied in Ukraine. That was from 2013 to 2019. That was a whole other experience. Honestly, the word I will use is blessed. I am glad I have mostly good memories of that time. There were a lot of cultural differences that occurred when I first went there, but it was a nice experience overall. At the school I went to there are some little things where, looking back, maybe I would have chosen another school just to get more hands-on experience. But at the end of the day everybody keeps learning, so I would not say that was a major step back for me. My time in Ukraine, I look back at it fondly. At the end of the day, that is where I went to school and [inaudible]. It was okay.

Jii: Was there a major difference? Because what we tend to think, especially for people who study abroad, is about the quality of education you get, especially for programmes like medicine. It is usually looked upon as, the rest of the world outside Africa is more advanced. Was that the case for you when you came back?

Dr. Nana: I can only speak from personal experience. Like you said, there is always this impression that once it is outside Nigeria it is better. I do not know why we do that to ourselves.

Dr. Nana: Personally, the reason I went to Ukraine was that my initial JAMB results were incomplete. I think one of my results was incomplete. If I go back to the subjects, English and then physics, chemistry, biology. I think one of them was not there. The result was not there, so it was an incomplete result. So I had to wait till the next year. I wrote them again, but we also started the Ukraine pathway, because we had heard good things about it. At the time it was somewhat affordable. And then there were those added benefits of it being outside the country. So it was, let us try this outside thing and see where it goes. And like you said, there is that mentality that outside should be better.

Dr. Nana: Getting to Ukraine, there was the shock. Even before this war that is going on, even before that happened, something I learned about their lifestyle is that they are not very rich people, at least not by our standards. But there is a level of accessibility for the general public that is present, which I like. Most people across all boards have access to certain things, and it is not going to lead to bankruptcy.

Dr. Nana: A lot of people know this thing in Nigeria, that you are literally a medical emergency away from bankruptcy, because healthcare [inaudible]. They have emergency services. I like how they structure their hospitals. I schooled in Zaporizhzhia, that is the city I lived in. There were multiple huge hospitals. There was a general hospital, fine, there were a few general hospitals, but there were also specialist hospitals. So when you had a problem they knew exactly where they were taking you. Let us say it was an emergency: you call the ambulance and they already were taking you to this particular place, which I really liked. Because if you are in the specialist hospital, there are lots of people who can deal with your problem. I really like that aspect.

Dr. Nana: Now for the schooling aspect. I studied in the English language. The city I lived in, they mostly spoke Russian at the time, but by the time I was graduating most people had shifted to Ukrainian. So I was taught Russian because it was compulsory, it was part of our curriculum, part of the language up to like third year or so. Because you also had to learn medical terms in Russian. But most of my classes were in English, my lectures were in English, because I was on the international faculty.

Dr. Nana: First year to third year is preclinical. That is the same thing we do here in Nigeria. Then fourth to sixth year is clinical. So you are doing all your theory first, first to third year. Then fourth to sixth year you are going to hospital regularly, you are seeing patients, you are attending clinics, you may attend some surgeries. As a medical student you are still a student, so it is not like you are necessarily doing anything, but you are there, you are observing. That is part of your learning process.

Dr. Nana: I would say that for sure there was a language barrier to some extent, because we learned some but we were not fluent. Some people grew fluent. People who dated the natives grew fluent very quickly. But some of us, it took a while. I was never fluent, though I could get around. So there would be some things that would hamper how much you actually understood. And in my personal experience, at my school, I think the main thing I will say is that language thing. Because there were quite a number of patients that were okay with us just being present, for the examinations or during the clinic. Some patients were actually okay with it, some people were not. And I am not going to jump and say it is a race thing, because worldwide, even here, sometimes patients are not comfortable with students being present. And honestly, it is how we learn.

Jii: That is interesting, because even when you go to an English speaking country, there is still maybe not necessarily a language barrier, but there is a social and cultural learning process you need to go through to understand how things are done, especially coming from Nigeria.

Jii: I wanted to go back to when you said the way their hospitals are structured. That is particularly important, because whether I like it or not it affects the way people see hospitals in Nigeria. And maybe not to go too deep, because this is an intro episode, but what are the things that could be done better, especially for Nigeria, for healthcare in general? The way Nigerian hospitals are built and shaped, not just physically but policy wise. What could be better?

Dr. Nana: Like with a lot of things, it really helps when the government invests in developing the sector. Something I forgot to mention about Ukraine was that a lot of their things are government regulated slash government funded. Housing, schooling. So many things are regulated and funded by the government. Even the whole hospital system I told you about. To be fair, I think that is actually partially a leftover thing from when they were part of the Soviet Union. The whole hospital numbering system, I think it is a leftover thing from [inaudible]. But the government still upholds that. How do I put it? It is controlled by the government.

Dr. Nana: There were still private hospitals. You had the choice to go to a private hospital, no one will stop you, of course you simply have to pay out of pocket. Which is fine. But what I admire about that system is that everybody gets a chance. At least for some basic stuff, everybody gets a chance. It is not that somebody who is struggling and living paycheck to paycheck has a medical emergency and then they literally have nothing left, and you have to start crowdsourcing. Which would have been beautiful if it had just been covered by insurance or something. Simple, like the NHS in the UK, where you do not have to, you can literally be a homeless person and access medical care.

Dr. Nana: Because health is so precious. My God, health is so precious. It is really sad. It is difficult to get people what they need sometimes. And the only way I see that happening is the government providing funds for these sectors, because at the end of the day you cannot expect it to be done on a volunteer basis. [inaudible] And there are so many different components, so many things that make up healthcare. I feel like a lot of people just see doctors and nurses and pharmacists, and lab scientists, and that is it. People see these four professions and it is like, okay, that is it. But there are so many other people working behind the scenes that make healthcare what it is. There are a lot of administrative duties, there is a lot of sourcing, budgeting. There are so many things involved that require additional funding. And for it to be accessible, the sector has to properly be invested in by the government, or whatever country it is.

Dr. Nana: For me it would be beautiful if healthcare could be accessible to everyone, because of how precious health is. But because of the way things are for us currently, most people are going to prefer private healthcare because of the resources and things that are available there. And private healthcare is going to continue to be expensive, because at the end of the day you need money to run these places. So it is kind of just a sad cycle. Healthcare takes a lot of money to run, and for it to become very accessible to the general public it needs to be taken care of by a huge body. It needs to be invested in.

Jii: True. That is the government. And I totally agree. Anything that is going to move forward in any country, whether I like it or not, needs to be initiated, needs to be regulated, needs to be pushed by the government. Because from the government standpoint it is not going to be necessarily profit driven. It is going to be for the people. But for private companies it has to be profit driven, because they need to continue running the business. Even at the point where they are saying no, we are doing it for charity, at some point they need to make money back to continue to run the business.

Jii: I want to shift from that quickly to the people. What is the public conversation about health in Nigeria? What is the general idea? And it does not have to be one thing. This is from you, what you hear, probably from patients. I know a popular one is that they do not like going to the hospital. There is this popular belief about going into the hospital and not coming back. And if it gets to the point where you need to go to the hospital, it almost means the case is terminal. From what you have seen, what is the general public conversation?

Dr. Nana: Similar to what you said, there are some people who do believe that, and it is very ironic. What you said about people believing that if you have to go to the hospital it is terminal, that is especially true for when people go to tertiary institutions.

Dr. Nana: I think I would have to do a little bit of explanation here. We have primary, secondary, and tertiary institutions. Primary institutions are things like primary healthcare centres. They are not a complete proper hospital, if that makes sense. There is usually a doctor on ground. It is more or less just a clinic, not really any admitting facilities. But these are institutions that can deal with the regular day-to-day small complaints that patients have. You usually find these in rural areas, actually. And these address a lot of their little problems. It meets the need for that.

Dr. Nana: Then you have secondary institutions, which quite frankly a lot of are private institutions. You can have some admitting facilities but they are still limited, both in ICUs and so on. Then you have tertiary institutions, like teaching hospitals. And a lot of people fear teaching hospitals because of the thing that you said. Because they are like, I am going to so and so teaching hospital, we know of this person who went there and they did not come back.

Dr. Nana: The sad thing is, if you actually dig deep into the cases of people who died in teaching hospitals, you will find that their health journey did not begin there. Whatever the progression of their illness, it has probably been going on for a period of time, and they usually started somewhere else. Somewhere more affordable to them, or somewhere of easier access to them. They have usually started trying to seek help somewhere else. Time has passed, things have not gone too well. They have been referred and referred and referred. And then they end up at the teaching hospital towards the tail end of the journey, and finally pass away there.

Dr. Nana: There are times when getting to the teaching hospital, because at the end of the day the teaching hospital is where you see a multitude of specialists, so ironically it is your best bet. Because if they need to refer you to someone else, they are likely going to be within the same facility, and they come and see you.

Dr. Nana: It is just that a lot of the time we tend to, as humans, and I think especially as people in the workforce, young and older people in the workforce, we may get certain symptoms and we do not really take them so seriously. We try and manage, and we are like, okay, it is not that serious. Fine, I will take a paracetamol here and there. Okay, I will sleep more when I get the chance. And by the time you are not getting better, that is when you start to panic. You complain to somebody and the person says, my friend had the same complaint, they used this, so you should try it. Things like this can cause delays in finding out what is actually wrong.

Dr. Nana: And by the time you get to know what is wrong, and you are referred to the place where you may be able to get help, which is a tertiary institution, and it is not only teaching hospitals that are tertiary institutions, there are actually some private facilities that have that much infrastructure and are also considered tertiary institutions. But by the time you are referred to a tertiary institution, it may already be too late. The disease progression may have already gone so far, because there is a limit to what you can do. Early detection of any disease is crucial in resolving it and reversing whatever effect it has had on the body.

Dr. Nana: I am sure there are people who hear somebody died and they died of malaria. And for us Nigerians it is, malaria? This simple malaria killed somebody? What do you mean they cannot treat the malaria? But what most people do not know is that malaria is a parasite in the bloodstream, transmitted by a mosquito bite. And what a lot of people do not know is that these parasites keep multiplying. They literally keep multiplying, because that is what parasites do. And they get to an extent where it is basically an overload on the body.

Dr. Nana: And the thing is they target red blood cells. So by the time they have gotten to a certain amount, because they end up destroying red blood cells, if you have enough red blood cells destroyed you become anaemic, that is, your blood is low. And that leads to its own complications. There are so many complications that can come out of simple malaria. And why do these complications come about? Because treatment was not started early.

Dr. Nana: Standard treatment for malaria is the usual artemisinin-based combinations, things like your Lonart, your Coartem. And if you catch malaria in time, you can literally take it from your house. You do not even have to miss work, you do everything and you are fine. But somebody who has been having symptoms, does not get checked, does not really take care of themselves, it can get so bad that they have cerebral malaria, which is somebody who has malaria and is having neurological symptoms as well. All from malaria.

Dr. Nana: So I think it is multifactorial, but sadly some people definitely do not have health seeking behaviours. And I am guilty. I am not even going to lie to you, somebody who works in the healthcare sector. We try to minimise our symptoms. Okay, no, we are fine, I will be fine. And then sometimes that can lead to dire consequences.

Jii: I like how you systematically broke it down, and used early detection, all the way from primary to tertiary. And one thing we kind of talked about is access. Access, which now goes back to money. Most people try to minimise it or push back, because even the teaching hospitals or the government owned hospitals are not necessarily cheap for some people, because of the economic factors in Nigeria.

Jii: Before we pivot back to you, what is the wildest thing you have heard in the consulting room? What are some of the wildest things you have heard people say that you had to correct on the spot? And honestly, you do not need to shy away, because I know Nigeria is very cultural.

Dr. Nana: The thing about working in healthcare is that I swear you see people at their worst. Not just sick people, in the sense of [inaudible] their body and them in such a bad situation. And I am not trying to blame or say that people should try and be at their best, because it is difficult. Being unhealthy is difficult, and it is difficult not just on the person that is unhealthy but on the people who care about that person. It is really difficult. There is usually a lot of pressure at the time. And I am speaking as a healthcare worker and as somebody who has had a sick relative. So it is difficult. Being unhealthy is very difficult on everybody involved.

Dr. Nana: So sometimes there are people who have said things and have come back later to apologise. They are like, I am sorry. And I think this is just a part of being human. Though the thing is, the people on the receiving end of it, sometimes we have to develop a means to just brush some things off, because it can be bad for your mental health sometimes.

Dr. Nana: There is always this mindset, let me not say always, but I think it is a common mindset, where people are like, okay, we are recommending certain things because we are trying to get money. So there is something very common with our people, and honestly it is understandable. A lot of women want to give birth vaginally. That is understandable, and frankly speaking, that is the way we were designed. So that is what we want. A lot of women want to give birth vaginally, a lot of people do not want CS. But there are some cases where a CS is necessary if we want to ensure that both mother and child are fine. And for us, at least that is something I kept being taught, a successful delivery is one in which both mother and child are fine. It does not matter how it happened. We want the two of them to be well and okay.

Dr. Nana: But I feel like I have to sit down and think. I have heard a lot in this field. The common thing is like, it is a cash grab, nothing is actually wrong with my wife. But a lot of times it is a necessity. It really is a necessity. The baby could die, [the mother] could die, both could die, and that is really tragic, honestly.

Jii: And I think that will happen. Most people have that thought when there is money exchange. Whoever is paying for a service usually has that at the back of their mind, that they are being ripped off. Especially when they feel they are not getting enough value in exchange for what they are doing. Interesting. And I think it is cool that some people come back to apologise.

Dr. Nana: And at the time we understand, because at the end of the day we are healthcare workers, but we too are not always healthy. We experience the same things as well sometimes. So we can understand. Also, where I work, I have no access to billing. I do not know how much tests are. I mean I have access to check, but that is the billing part, that is not me. I am solely focused on the patient. That is usually how it is for a lot of people. Those things are not particularly [inaudible].

Jii: Would you do this again?

Dr. Nana: Well, if I could go back, I probably still would. But this is a personal thing. I wanted to be a doctor since forever. So this really was just the conclusion of a process that had started. It was, no, I am going to be a doctor, I did not give them any other choice, it is going to be a doctor. And I also thought about media, like writing on the side. There are a lot of people in medicine who write, screenplays, books and stuff. So that was the ideal for me growing up.

Dr. Nana: I still remember, I saw one of my old journals when I was younger or something, and I remember seeing what I wrote, and I was like, I am going to be a doctor. I was like, I am going to be a neurosurgeon. I have no interest in neurosurgery now. I am going to be a neurosurgeon, I am going to write books as well. I had plans to be awesome. I love little me. I love how enthusiastic she was.

Dr. Nana: I think I would. Probably still would, but I would tweak a few things along the way. Because, like the thing we say sometimes, medicine takes everything from you, so it becomes difficult to see yourself doing anything else. So the important thing is to strike a balance, which is what I am trying to do now, trying to make sure I keep my other interests alive. So I probably still would.

Jii: Anybody who is in the business of saving lives, especially in Nigeria with so many factors that seem to go against the healthcare profession, and then coupled with the cultural nuances of the people you are trying to help, it is pretty awesome. But going down that lane of striking balance, just for people to get to know you more: what do you do in your downtime? I do not know how much downtime you have, but what are some of the things you dabble into?

Dr. Nana: I have always liked the arts on some level. Books, literature, movies, comic books, anime, manga. It is funny, I have liked stuff like that since secondary school, since I was little. So that has not really gone away. Of course there was a period in time where I kind of just lost it and I was not really indulging in things that I found interesting. But over the past few months I have tried to go back to those things I used to enjoy, and so far it has been good.

Dr. Nana: I also like food a lot. I like delicious food. I do not like making it but I like eating it. So I try my best to find new things that will stimulate my palate. I try not to shy away from trying out new things. I read a lot. I read quite a number of novels. I have novels on my phone, I have physical copies of books. I watch movies too.

Dr. Nana: I try to journal to de-stress. Funny enough, when I am emotional I do not journal as much, but when I am under a lot of pressure, that is when I tend to journal. It helps me clear my mind. And I spend time with people that I like. Go to the cinema. These things come in waves. There was a period of time where I was painting, going for all these sip and paint things. So I have quite a few of those, pottery, paintings, something like that. And we do these things as group activities. I literally went out with two of my friends who are also doctors yesterday, and we went to a gallery after. Just stuff like that. It helps, we spend time outside work.

Dr. Nana: And I try to keep work at work. Sometimes I joke, I have friends who are not in the medical field and I did not meet them in the hospital, but then sometimes some of them will literally say, Dr. Nana, and I am like, you did not meet me inside the hospital, I do not understand why you are calling me this.

Dr. Nana: So that is what I try to do. I am just like any other person, honestly. I think work life balance is important. I think it is so important. Because at some point, if you do not have that, it breeds resentment, and then it is like, what am I even doing here? And then you get burnt out really quickly. I think I have experienced burnout and it is not nice. It is not nice for you, it is not nice for the people you are attending to, it is not nice for your colleagues. So it is good to have a balance.

Jii: Two questions. First, what anime are you watching?

Dr. Nana: Sorry, like a fangirl, like a proper fangirl.

Jii: Last question. Favourite superhero.

Dr. Nana: My favourite superhero. To be honest, this is not really even a question. From the days of Sony, I do not think I have liked any other superhero except Spider-Man.

Jii: Did you say Spider-Man?

Dr. Nana: Spider-Man, yeah. I do not know if I will sound like a purist, but Marvel has its issues and stuff like that. But literally from the days of Tobey Maguire, I have always been Spider-Man. There was never anybody else.

Jii: Have you seen the new Spider-Man?

Dr. Nana: I have not. I want to.

Jii: That was my last question. Expect Dr. Nana to come on as often as possible. We will talk about the health sector, we will talk about why people should take their health seriously. We will not prescribe any drugs or medicine, we will not diagnose you. We are just going to have a conversation around the health sector.

Jii: Thank you, Doctor Nana. So when you are on the pod, should we call you Doctor Nana? I think I would like to call you Doctor Nana.

Dr. Nana: [inaudible]

Jii: Thank you Doctor Nana for coming through, thank you for speaking to me on this intro episode. Any last thing you want to say, maybe about what people should expect, before we bounce?

Dr. Nana: I think this is new for me, so I would love to just be as helpful as I can be. I would love to share useful information as much as I can. And I feel like I am probably going to give a lot of personal anecdotes whenever I talk about things, because these may be things I have experienced or that I have seen happen. So I look forward to the coming episodes. I really do. And I really hope they help people, and get people to take health more seriously.

Jii: Same. I hope so too. And people, listen, take your health seriously. Thank you, Doctor Nana. We will see you next episode.

Dr. Nana: Thank you for having me.