Day 30: Birthday Party & Going Home! *updated*

Hello, I'm going home today! I'll post more about Day 29 when I get back home (I had to give my plug adapters back to Dayo so I couldn't use my laptop last night) but I'm waiting for my ride to hangout at Mayowa's family home before my flight later tonight.

Thanks for reading and I'll post more when I return to Chicago!

*****
Last night, I fell asleep with excitement that I was going home! Don't get me wrong - I really enjoyed my stay in Nigeria. I had felt personally challenged and am going home feeling gratified about my experiences. I met many new friends and had first hand insight on Nigeria during a time of its all important elections. I liked the local shopping and even the local food (catfish!). The things I enjoyed far outweighed the things I didn't like (heat, African time, insects, dirty, poverty) but a month's time is a long time to be away from home from loved ones. There is nothing like home!

I had packed my luggage and was hopeful that the luggage didn't exceed the weight limits (50 lbs is like nothing!). Mayowa, Sope's nephew, was going to pick me up after the check out time from the hotel so that I won't have to pay a 1/2 day of hotel. Unfortunately, he got called into work on the Saturday and his younger brother, Ayo, picked me up and to my surprise, I was dropped off at his younger 10 year old brother's birthday party! Their younger brother had turned 10 on March 31 but because of elections, he couldn't have his big and fun birthday bash until today.

The party was quite lavish and big. Many children of all ages and many parents and adults present as well. The kids were pretty well behaved sitting and eating their food. They also stood in line quite well (and very patiently) to get popcorn, hot dogs and ice cream as snacks. They had a large inflatable jumping thingy (I'm not sure what this is called) to play in. What I thought was cute was that when the the emcee for the event (he was hired and had appeared to have hosted many a birthday party) told everyone to get ready to play games, he told everyone to sit down and put on their shoes. Lots of kids were running around in the dirt barefooted.

The main highlight of the event was the dance off between girls and boys. Here is a terribly cute boy that definitely had moves. He danced like a Michael Jackson to Justin Bieber. So cute!

The emcee orchestrated a dance off between the mommies of one of the girls and boys and then, the emcee had a dance off between the birthday boy's mommy and daddy and later on, their respective male/female friends. The birthday boy's mommy and daddy were very well natured to participate! The person with the best moves among this group was a 70 year old grand pa! He could bust a move!


They played a game where the men had to tie a gele for a woman. Hahaha. Most men couldn't do it!
Awkward moment of the birthday party was a woman asking me if I liked blacks. Yes, she asked me if I liked blacks.

I had to leave before the end of the festivities but here is a picture of me with the birthday boy, Mayowa and their mom!
I picked up two gift bags to commemorate this important birthday to bring home for Sope's kids (the birthday boy's cousins). A yellow personalized bag with a thermos (personalized of course courtesy of mum and dad) and a bag of candy and snacks.

Mayowa and Oyinda drove me to the airport. Of course there was a ton of traffic. In the airport, I got hassled a bit by the United rep about my book bag. She insisted it was too big. I had hardly anything it! I had my luggage hand inspected but the inspection was far from thorough.

On my way to the security line to clear immigration, I was "accompanied" by an airline rep who told me he was to help me get through security. Ahh.. yea? Sounded a little fishy. As it turns out, he put me in the fast immigration line and asked for "a token of appreciation" = BRIBE! He asked for $20 USD. I gave him a look and flat out told him I had not USD (which was a lie) and ended up giving him 400 Naira (= $2 and change in USD). I had finally paid my first bribe in Nigeria!

I had my carry on luggage xray scanned and hand inspected again at the gate in Lagos. The airline rep at the Nigerian gate took issue to the thermos and made me open them all up. The airline rep in Ghana (had a connection in Accra) took issue to extra batteries I had on me and my hairbrush. I relinquished the batteries. When I finally landed in the US, I crossed immigration pretty easily and Homeland Security took issue to the peanut butter and Nutella I had in my bag. I guess peanut butter and Nutella is considered a liquid. But whatever, I'm back home!

Thanks so much for joining me along my 1 month adventure in Nigeria. I appreciated all the positive feedback and encouragement esp as there were many days I didn't want to blog and certainly wanted to go home. It was nice to share my experiences and someday, I hope to return to see the progress and improvements that will happen.

I'm glad to be home and thanks for reading!

I'll post again when Eddy and I try on our matching outfits!

Day 29: Ward Rounds & Live Catfish!

Day 29 marked my final day of "work" and meant that I was going home really really soon! (Can you tell that I am looking forward to going home?!)

I met in the resident work room a little before 9 AM and the consultant arrived at about 9:15 AM. Not bad. We started rounds relatively promptly considering African time. I was a little confused at first because the "consultant" that had arrived was introduced to me as a senior registrar the day before. As it turns out, he just became a consultant (having passed his exams) in Cardiology.

We rounded on about 16 patients scattered throughout the hospital. We first went to the emergency room wards for both men and women. Unfortunately, while we were seeing two of the male patients, one of the neighboring patients was noticed to be expired (= dead). There were flies landing on the man's body but his body never moved. It looked like he had been dead for a while. I was slightly alarmed given if this had happened in the hospital where I work in Chicago, the nurses/staff would have likely called a code blue/Dr. CART for a cardiac arrest. Here, we just went on with things. The nurse put up a removable room divider to give the patient more privacy (there are no curtains or separate rooms - just one large room filled with 12-15 patients). One of the house officers stepped out of rounds to complete the death examination.

One thing I've noticed both here and in Ibadan is that despite having a Cardiology or Pulmonary or Endocrinology service, by and large, these services are just General Medicine services. They admit any and all medical patients via the ED and occasionally get consulted by other services for specialty specific consultations. I was participating on Cardiology service ward rounds and only maybe about a quarter of the patients had an active cardiology issue. Among those with cardiology issues (this is going to get very medical now) included dilated cardiomyopathy (presumably non-ischemic but none of them had any type of cardiac catherization (it's too expensive and there are no facilities for it available on site), decompensated heart failure, and endomyocardial fibrosis which is a type of restrictive cardiomyopathy common in tropical areas with eosinophilla. Didn't seem like the endomyocardial fibrosis was confirmed with biopsy of heart tissue (as this is commonly done in an interventional manner) but rather diagnosed in a clinical manner. The other types of patients we saw included a man that had not walked in 3 wks (presumably had a neurological lesion but had not had any imaging yet), a man with likely terminal cancer in the abdomen with a large swollen belly of fluid and significant cachexia and a young boy with some type acute leukemia that was languishing. It was not an uplifting morning.

It was still very evident that patients that had little or no money did not get the standards of care though it may be possible that these patients got more care on admission than patients in Ibadan. Not sure about that. It became apparent that patients at least 60 years or older when admitted did not have any costs. Their families had to pay for emergency care if they went through the ED but by and large, the rest of their medical care once they were admitted was free. Glad the Lagos state government it taking care of the seniors. I also learned that one session of hemodialysis costs 40,000 Naira each and every time. They place temporary catheters to do dialysis in the groin and remove them every week. They don't have problems with catheter associated line infections.

Remember how I showed you pictures of the newer hospital ward? Apparently, that is the only hospital ward that appears that way. While seeing the 16 patients, we went into a variety of different hospital wards that were all in different states of cleanliness and modernization. The newer ones were large rooms with 16-20 patients without any curtains. There were fans and screens in the windows. The more run down hospital wards were dingy (and smelly) with some fans and often times, compromised window screens. Unlike Ibadan where all patients had bed nets, virtually all of the patients did not have bednets, definitely placing them at risk of malaria.

The consultant leading rounds, despite his junior status, I could tell had subscribed to the culture of the consultants I've seen in Nigeria thus far. He dictated his notes to the house officers/resident and never washed his hands between the 16 patients. He taught a little bit and even pimped me (not nice to pimp the guest!). I thought he did a nice job telling a gentleman that he likely had incurable cancer and that he should go home (as opposed to stay in the hospital). However, given that his area of specialty is in Cardiology, I thought that he would spend more time teaching cardiology when we came across the more cardiology focused patients. Unfortunately, this was not the case. In some situations, I felt that perhaps the patients were missing out on potential benefits of therapy (i.e. getting a ACE in heart failure as opposed to digoxin). For the residents, I felt bad because they were barely learning anything beyond transcribing the attending's note and his plan. There wasn't much teaching outside of this. We even saw a patient that had a pacemaker for a second degree heart block complicated by the pacemaker pocket infection (I've seen a gazillion of these cases in Chicago) and then had a new one placed and found to have ventricular tachycardia. When I heard about this case, I instantly thought that there was so much to learn and to teach! Sadly, the consultant dictated his plan of getting a EKG, reviewing the EKG and checking a basic metabolic panel. No discussion of what is ventricular tachycardia, who gets it, how to work it up, what to do let alone learning about pacemakers, indications for pacemakers and second degree heart blocks. We never reviewed any EKGs (because the patients with exception to 2 did not have one done) and of course never looked at telemetry because there was none except for one patient that had a transport monitor at his bedside. I was totally unimpressed. When rounds ended, the consultant didn't even address us and walked away. As I said, totally unimpressed.

Though it was nice to finally experience a hospital that had running water and electricity, I could still see that the dysfunctions and lapses in professionalism that was seen in Ibadan still persisted despite the existence of water and power. Whereas in Ibadan I had started to blend in and become part of their community, I was just the visitor that was in Lagos for a brief time asking questions here and there so who knows if my observations are clearly representative of what is actually going on. I also missed out on chart review (= morning report) as it was canceled due to resident meetings. I heard that they used NEJM cases instead of actual cases for these chart reviews.

Later in the day, I finally ate the highly recommended live catfish! Dr. Adekunle took me on a 7 minute walk to a side street near the hospital to pick out a live catfish. You don't actually eat the live catfish but you pick a live catfish, they kill the fish right there and then and then cook it really nice and hot and spicy.

On our way there, I thought I was going to die crossing the street. Literally. Remember those pictures from Day 27 where I was sitting in traffic trying to get to the post office? Well, that was the traffic I encountered while walking to get live catfish. Dr. Adekunle laughed at me and held my hand when we crossed the street on the way back. Yes, I know. I'm a scared oyibo.

Here is the selection of live catfish. They barely moved until of course the owner lady poked at them and then I jumped and yelped (still probably skittish from walking in that traffic).


Here are the two we purchased. One for Dr. Adekunle and one for me. I wasn't sure I could finish one but Dr. Adekunle assured me it wouldn't be a problem. It was 700 Naira per fish. Good deal!


Here is the piping hot and spicy and peppery catfish. The spiciness reminded me of Korean spices. My nose starting running when I was eating the fish. I think Nigerians would like Korean food which I heard isn't really available in Lagos. (If it's not available in Lagos, it's not available in Nigeria.)


I did have a small stomachache the next day (probably because of the spiciness) but it was totally worth it! This was probably my most favorite Nigerian food. I want to have it again in Chicago.

Dayo dropped by from Ibadan and picked up my cell phone and plug adapters. He also dropped off our matching clothes made for Eddy and I. They look very cool! Maybe Eddy will let me post a picture of us wearing them. Now that we have matching clothes, I hope we will get invited to a Nigerian party in Chicago!

It's happening! I'm going home soon!

Day 28: Diabetes Clinic, Pharma & Going Home

Today, I started off the day going to the post office. True to form, the post office had not opened even though it was past 8 AM and a small number of people stood in front of the door to encourage them to open the door. When the office finally open and I made it to a station, the clerk was a bit confused as to why I was buying stamps (?collecting?). I wanted to buy a whole sheet but just couldn't justify spending over $50 USD on stamps I would never use. In the end, I spent a bit over $10 USD for two different types of stamps. In the post office, people were cutting in line in front of me left and right. Given I've been in Nigeria for a while (plus I'm hot and tired after 4 wks away from home), I sort of gently (as gently as an Asian girl can) snapped at a man who was standing really close next to me while I was still doing my transaction. Can I get some personal space when buying my stamps?!

In terms of hospital work today, I learned that the things that were on my schedule weren't going to happen. I was scheduled for Neuro rounds (spoke to the consultant = not happening), Gastro rounds (spoke to the consultant = not happening but there was clinic starting at maybe ?10 AM), and Endo clinic (the consultant's phone was off). I ended up hanging out in the resident work room and chatted with a few senior registrars which coincidentally were all women. They were all very pleasant and we discussed the differences in our training systems and call systems. Unlike in the US, there are no such thing as resident work hours nor limits on the number of patients you take care of or admit in a day. You take care of all the patients that need to be taken care of. A couple of them will be in Chicago early next month for a GI conference so we exchanged info. They wanted to know what to wear (is it windy? is it cold?) and where to shop.

I made my way over to the Endo clinic and found that it was in progress. The consultant was there with 2 training physicians. One training physician took the blood pressure and wrote the follow up appointments on their appointment cards. The other training physician filled out prescriptions and lab sheets. The consultant wrote her own notes which later I discovered included the patient's blood pressure, fasting blood sugar (if diabetic), their medications and her signature. Very abbreviated; occasionally some physical exam findings or a sentence or two about the patient if they had any fresh (= new) complaints.

Overall, I was not too impressed by this consultant as she spent very little time interviewing (and examining) each patient. Plus, our patient encounters were frequently disrupted by other patients, ancillary staff, pharma reps (who ended up staying in the room and assisting, more on this later), a visit by a friend with her friend's 7 month old infant (which she held and cooed with) and of course, a bazillion phone calls. Of course, when a patient's phone rang, the consultant would gently scold the patient for leaving their phone on. At some point, I think we were seeing 2 or 3 patients at one time in the same room. I'm getting tired of these lapses in professionalism.

To give this consultant credit, I could tell that she had been quite industrious and traveled quite a bit at endocrinology conferences to present as her original research posters were hung throughout the patient room. She had been to the US for a 3 month posting as well. She was conducting a trial of vitamin E and another medication for diabetic patients with neuropathy. The training physicians were spending most of their time enrolling these patients in the trial (weighing them, taking BP, waist circumference) while she continued seeing other patients in the same room. I'm not sure if there was even really true informed consent.

Clinically, for the most part, the patient were on appropriate medications for their diabetes and they were very good about checking everyone's blood sugar and blood pressure. However, there was an instance in a patient that had uncontrolled blood pressure and wasn't on a type of blood pressure medication (ACE-inhibitor) that has proven benefit for diabetes. I asked about why the patient wasn't started on this medication and basically learned that there wasn't a really good reason why she wasn't. Before asking the consultant, I had quietly asked the training physician sitting next to me and he knew too that the ACE-inhibitor would be ideal but didn't want to ask as well. Plus for the same patient, the patient's family member astutely asked if potentially her diet could be contributing to the high blood pressure. The consultant said no! Ahh... yes... diet contributes to high blood pressure and this was seriously a miss-managed opportunity.

I could tell there was a strong pharma influence in the way this consultant (and subsequently the training physicians) prescribed medications. They were prescribing high cholesterol medications that even in the US are very expensive (i.e. Crestor, Lipitor) that I have no idea how the patients are going to afford them when slightly inferior but still very good high cholesterol medications that are much more affordable do exist (i.e. simvastatin). Later on, this type of behavior made more sense to me as a pharma rep came to visit and stayed in the clinic room for about 1 hour, providing advice about what medications to write for. Talk about pharma influence left and right and breach of patient confidentiality. When I asked the training physician who this person was (the pharma rep), the training physician said he was the pharma rep and that he was very helpful. I guess when you are short staffed, you need everyone to help. But I'm not sure if this type of help really benefited the patients esp when I am confident most patients can't afford the brand name medications that are being prescribed.

I also learned a bit about the struggles of diabetic patients in Nigeria. Insulin is very costly (40,000 to 50,000 Naira a MONTH) and needs to be refrigerated. Clearly by now, you must understand the challenges with simply refrigerating things with shotty electricity let alone just purchasing the medication itself. Thyroid function tests cost about 8000 Naira and take 2 wks to come back. For those patients that enrolled in the study above, they get free hemoglobin A1cs to measure their glycemic control for the last few months. At least they were able to use hemoglobin A1cs to make clinical decisions. Also, the consultant acknowledged that diabetes should get at least yearly eye exams but admitted that the eye clinic was very backlogged. We also did no foot exams to look for foot ulcers which is a standard of care in the US for diabetics.

The consultant did ask me for feedback and I talked about how consultants in the US see the patients every day on the wards. She seemed incredulous about this and quickly said that this wouldn't work in their system. However, I was taken aback by this as the leadership and some consultants in Ibadan had acknowledged the benefits and necessity of increased supervision by the most senior physician. LASUTH has the luxury of having pretty continuous electricity and running water that is not present at Ibadan. But in speaking to this consultant, I felt that despite this facility improvement, the cultural change in medical education and patient care was likely going to be a much greater challenge in LASUTH than UCH.

After taking a breather from the Endo clinic, I ate lunch (I've learned that I just need to step away if I need to eat) and tried to go to GI clinic which unfortunately was already done. Then I tried to figure out if I could go on ward rounds but discovered that had been completed and according to the resident, "I didn't miss anything." Okay. I guess I'll try tomorrow. I'm suppose to go on consultant Cardiology rounds tomorrow. I must at least see this before I leave.

I tried to walk around to take more pictures.

Here is the Endo clinic.


Here is the makeshift "studio" where I got passport pictures taken to have an ID made the day before. I thought it was very appropriate to get an ID (so ppl would know that I was suppose to be around). However, I'm not sure if I'll get the ID before finishing tomorrow.


Here is the front of the modern diagnostic center. Look how one of the doors is opening? Just after I snapped this photo, a guard came out to interrogate me about why I was taking pictures. Of course.


Here is the empty patient waiting area for the medical outpatient clinics.


Being in Nigeria for this last month has been a personally challenging but gratifying experience. I think I am a better person and physician because of it and I know that I will be much more patient and cost-conscious in my medical practice. I appreciate electricity and water on a whole new level. I feel a lot of sadness for the patients I have seen and for the widespread poverty that is present but I have tremendous hope that Nigeria can and will improve in time. Nigerians have been such a good host in making my trip as comfortable and as pleasant as possible. But I still can not wait to go home!

Day 27: Grand Rounds, New Perspectives, Election Update & Traffic

Today was my first full day at LASUTH. It started the way I had anticipated - waiting and more waiting but with lots of pleasant conversation. By now, I'm accustomed to African time and making adjustments to it. To be fair, my posting at LASUTH was arranged at the last minute and the hosts have been nothing but accommodating and hospitable.

In the morning, I met with Dr. Bode who had 3 different Nigerian newspapers with him. He said it was okay for me to take pictures. Here are the headlines:



Yes, there are underage boys voting and gunmen snatching ballot boxes but still more peaceful and transparent than before.

Here is the president-elected and governor elected of Lagos, both winning reelection. Their pictures hang in many people's offices and building just like I've seen at VA hospitals in the US and everywhere in Asia.

Dr. Adekunle stopped by to say hello and gave me a quick tour. Since he is a dentist (and has worked in the US in mental health and dentistry), he paid special attention in showing me the dental facilities which were quite nice and in a new building. Dental care (compared to the US) is relatively more affordable (1500 Naira = $10 USD for a dental cleaning) but no type of insurance coverage. Everything is out of pocket. Dr. Bode is an orthodontist. They tell me a few Nigerians get orthodontics done. Dr. Adekunle commented on how my teeth looked pretty good (I had braces over 15 years ago). My orthodontist would be proud.

Here is a newly built hospital ward at LASUTH. About 2-3 years old. There are 5 semi-large rooms to house 4 patients and there is 1 private room with air conditioning. The other rooms have 4 fans and running water. I asked how frequently they had running water. The nurses said all the time. The other rooms are for equipment, family waiting room, and physician and nurses work stations. The patient bathrooms are at the end of the hallway.

On the way to the wards.


A pod for 4 patients.


We also walked through the Surgical Emergency room. Unlike the Medical Emergency room, when you walk in, there is a sign that lists the consultant in charge and his phone number. Ventilation here was again poor despite some air conditioning. There were gurneys throughout the hallways. Many of the patients were men, likely from road vehicle accidents, many with lacerations to the head.

We toured a mini-ICU and there was a patient on a ventilator and there were actual functioning monitors. Three of them to be exact! When the I heard the sound that the ventilator makes when the patient breathes over the ventilator, I finally heard something familiar!

Here is an ambulance. In theory, if you call 767, an ambulance come to you. These are use to transport patients within the hospital complex from the ward/emergency room to the CT/MRI scanner in the super new modern building.

I met with the head of the medicine department as she was finishing her dermatology clinic. Her last patient was an albino. During my month long stay here, I've seen a handful of albinos who have pure white skin throughout. This patient had the unfortunate circumstance to have a huge, fungating ulcer on his lip that was likely some type of skin cancer. The patient allowed the consultant to take a digital photograph but then promptly covered his mouth with a handkerchief. Even after we all had seen the lesion, he kept the handkerchief over his mouth while trying to take something out of his bag to give us. It was quite disfiguring and must be very distressing for him. I learned that albinos, unlike those with vitiligo (just patches of white skin), tended to feel proud of their white skin color and many do not adopt habits to protect their skin from sun damage like hats, sunglasses and long sleeves, let alone sunscreen.

After we finished seeing this patient, the head of the department tried to arrange my schedule for the next few days. This all seemed very well intentioned but took a bit of time to locate the ward rounding schedule (consultants only round 1-2x/wk per unit and on different days per unit) and the specialty and general clinic schedule. Apparently, the specialty clinics rotate in being a "general medicine" clinic daily; this happens in Ibadan as well. There is family medicine at LASUTH and they refer to the medical clinics when they think some type of specialty care is needed.

I asked about the health coverage Lagos State extends to their constituents. Apparently, one must apply to get health coverage from the state government and from the way it was explained to me, it helped if you knew someone in the government or had some special relationship. Also, the National Health Insurance Scheme (NHIS) is apparently available to more than just civil employees but no one could really explain how one could apply or how the insurance provided coverage. Also, I learned that an predominant thought among Nigerians is that to get sick is to have wronged your neighbor. With this belief, to preach prevention, early detection and insurance might be naught.

Patients that come to Lagos State, without family at bedside, can get some basic services and labs and maybe an chest xray. How they were able to extend care to those financially strapped wasn't well detailed but I was assured that some degree of care was provided. In fact, the chief medical director cited at 2 million Naira fund for this purpose but I wonder how quickly it is depleted. Later on, in speaking to a resident in private, she admitted that those without family to help pay would get very basic care but no medications, no complex labs beyond maybe as a blood sugar or PCV and not really any imaging. I am getting a sense that perhaps in actuality the reality is less rosier than they are making it out to be but I am told the state of LASUTH and health care for Lagoians is by far better than it was 5-10 years ago. That is progress.

For lunch, I ate at Sweet Sensations which is a chain fast food joint that primarily serves local Nigerian food. It's a clean place to eat and it's in the hospital complex.

Here's what I had for about $7 USD.


Plantains, seasoned chicken breast/wing and Jollof rice. The Jollof rice is a bit spicy to my liking.

At 1 PM, I arrived to their conference room for grand rounds which was on a gastroenterology topic. To my surprise (and delight), we started only 30 minutes behind schedule! During the presentation, the power went out 3 times (with subsequent turning on of the gent). The presentation just continued without a pause! In fact, the residents generally can't tell when they are on the gent or getting power from NEPA because the same amount of light is present. This is unlike UCH where if we were on gent, only the emergency lights would be on, the ACs would be off and the sockets were all dead. At LASUTH, irregardless of who is supplying the power, the sockets work and the AC can be on full blast.

Anyways, I digress. I was pretty impressed by the organization and clarity of the presentations. More organized, less reading from slides. Appropriate and non-attacking questions by the audience. The residents were backed up by their consultant. The topic was irritable bowel disease which is more common in Nigeria that everyone had originally thought (most thing changes in bowel habits here are either malaria or typhoid). Afterwards, we had a brief pharma presentation for an anti-platelet agent. Yes, we got pens and free food and drinks.

I appreciated how the Cardiology and Dermatology consultants were inquisitive and seemed committed to retaining some of their skills as a general internist (as they have to see general medicine clinic as well). What struck me here and in UCH was that the number of consultants were very low. Only 2 to 3 consultants per subspecialty. I noticed this as well in Ibadan. I heard from the residents that consultant jobs are hard to find as well after graduation from residency. Seems to be a funding problem in paying for their salaries. Definitely short staffed for the volume of patients that need to be seen.

Afterwards, I saw a resident call room. It had AC and a cot and table. The residents bring their own sheets when they are on call. The senior registrar can stay in house if they wish but many just go home when they are on call. The registrars and house officers will call them if needed. Another thing I noted was that half of the internal medicine program at LASUTH was composed of women and one of the women was expecting later this year. Not sure why UCH had so few women in internal medicine in contrast.

After work, I wanted to go to the post office to get my mom some stamps. (We like to collect stamps from throughout the world; a little nerdy I know.) This is the traffic while we tried to get to the post office which in theory was less than 3 minutes away on under ideal driving conditions.

To my left.


To my right.


Straight ahead and our poor driver, Abudu. He can't really understand my English very well.


Lagos traffic craziness.

In the end, the post office was closed. Only open from 8 AM to 2:30 PM. Guess I will have to try tomorrow morning before work.

Day 26: Day of Rest & Reflection

Day 26 was the final 2011 election day for most Nigerians as elections in a couple of areas in northern Nigeria have been delayed due to somewhat regionally isolated violence. Curfew was in place from 7 AM to 4/5 PM. No movement except to vote. I slept in, watched some TV, played from Free Cell (I'm getting good at it now) and repacked my luggage (I hope they let me on the plane).

All Nigerians I have spoken to including the hotel staff, friends and physicians all reflect on how this election was by far the most peaceful and transparent in Nigerian history. Nigeria has a young democracy with the last vote in 2007 filled with much more violence and ballot rigging. In watching TV commentary, a common theme was the quality and intentions of the candidates themselves. Whereas we hope that people run for office to want to serve others and for the betterment of society and their community, there is always some element of self gratification and glory. In Nigeria, the latter may hold more true than the former. Plus, those elected to office stand to gain ridiculous salaries and benefits exceeding up to 1 million USD a year when most of the country subsists on less than 2 USD a day. In addition, extreme immunity laws are also in place for elected officials. As an elected official, they all have immunity from investigation and prosecution from corruption and other crimes. Talk about a motivating factor to do whatever it takes to remain in office. Now compounded with intense poverty and the urge to provide the most for themselves and their family, these are motivators to bring someone to try to become an elected official. To serve others and better the nation may entirely be a secondary or even farther goal.

In Lagos, its people feel confident that the incumbent governor, Babatunde Raji Fashola, will win reelection quite confidently and the early reports point to this as well. Most feel that he has done a lot of good for Lagos and have faith in his plans for continued growth and development. His posters with his face is most densely saturated in Lagos. Here is an example.

I've also learned a bit about the different ethnic groups in Nigeria which include the Yoruba (I've been in Yorubaland during my whole trip) who predominantly live in the southwest, the Hausa from the north and the Ebo in the east. Each group has a distinct native language, cultural practices and religious beliefs. Many of the Yoruba I have met are devote Christians with some Muslims as well who all seem to be very religiously tolerant. However, from what I understand, the Hausa, who are overwhelming Muslim, subscribe to more extreme Islamic beliefs. The Hausa Muslim will not pray with a Yoruba Muslim. Generally, women having very subservident roles (and limited opportunities for education) and children as I mentioned earlier are often sent from their homes at a ripe age of 8 to 10 fend for themselves without parental love and nurturing. There is also quite a bit of inbreeding where first cousins may marry as well. These children remain uneducated, trying to survive eat day and can fall prey to extreme Islamic sects that offer food and "love" in exchange for their obedience and participation in acts of violence or defiance against the government.

Poverty and lack of education with a religious undertone seem to be drivers of the violence and perhaps abject political corruption that has been reported in northern Nigeria. Since my stay here, no acts of violence in Yorubaland. To learn about how northern Nigeria was in contrast to my experiences in southwest Nigeria point to two different Nigerias - the southwest, led by Lagos, with economic growth and development and effective leadership and the north with religiously driven violence and widespread suppression of its people. Some Nigerians I have even spoke to suggest that someday not too far away (say 5-10 years), Nigeria may split along these lines. Thus far, there have been attempts for unity (i.e. relocating the capital to the center of the country to an entirely man-made city for that purpose, Abuja) potentially affected by the oil rich areas in the north (Lagos apparently has its own oil too). But some wouldn't mind if Nigeria was to divide. Of course my understanding of this situation may be flawed (and one sided, I haven't really spoke to any Hausas except to purchase things from them) as I'm relying on personal conversations with Yorubas but riveting nonetheless.

This is not to say that there is no poverty in Lagos. In fact, a young girl possibly no older than 5 or 6 years old begged through the car window on my way to Fela! Budgets of construction projects in central Lagos even include a fund to specifically bribe orphans/urchins that interfere with construction so that the children will allow the workers to continue to work. Clearly, there is still a lot of poverty and low levels of education in Lagos. But Lagoians, at least the ones I have spoken to, have a lot of pride of the improvements that have been made thus far.

Tomorrow, I'll be going for my first day in LASUTH. Looking forward to learning how things work here.

As I reflect on going home soon (yay!), here is a list of things I brought and/or learned that I thought was most helpful for my first trip to Africa. Not exhaustive but a start.

1. Purell. Water isn't readily available before meals and in the hospitals and plus, you aren't suppose to drink water or brush your teeth with water in Africa. I brought a larger bottle and a smaller bottle that I periodically refilled.

2. DEET lotion. This has worked for me and applying it to exposed skin has been a daily ritual. I think wearing long pants and long sleeves helps too if you can deal with the sweating.

3. Flashlight + batteries. Lots of light outages and if you are somewhere that can't run a generator all the time or in a place where you need to go out and turn on the generator, you need a flashlight. Plus, you never know when the gent might run out of fuel or malfunction. Thus, bring a flashlight and extra batteries for it.

4. Plug adapters. The plugs in Nigeria are like the British ones. This may vary by African country. I brought 2 so I could use both my laptop and also charge my cell phone and other things.

5. Moist face wipes. This was helpful when there was no running water to wash my face. Plus it was refreshing when I would sweat like crazy all the time.

6. Danskos. Yes, the medical heavy duty clogs. Nigerian hospitals are not known for cleanliness. You never know what you might be stepping on (and your good shoes might get ruined) and there are not always sidewalks to walk on. Danskos were good with protecting my feet and sturdy on rocky surfaces.

7. Make sure all your electronics have good battery life. This is specific to Nigeria and any other country with unreliable electricity. My laptop has crappy battery life. I wish I had replaced my battery before coming because once the power goes out, at least you can continue your activities with battery run devices. Also, when the light is on, charge all your battery operated stuff. Don't wait because the light might be gone by then.

8. Pocket sized tissues and/or handkerchief. You will sweat a lot even if you wear close to nothing. I carried pocket sized tissues (also helpful for using bathrooms without toilet paper). Most men had handkerchiefs in their pockets.

9. Take your malaria prophylaxis and vaccinations. It's not 100% effective but do you want to get malaria? Take it appropriately before and after the trip as well. Get a bednet if you won't be staying in quarters that are known to have good window screens (check for holes) and/or air conditioning. Get your vaccinations well in advance. Trust me, this will give you peace of mind. If you won't be in air conditioning, it might be worth it to bring a small plug fan.

10. Exercise good common sense. If you aren't black and are in Africa, you are like a light bulb. Even if you aren't "white" in the US, you are white here. Just accept that you don't blend in and that will make you somewhat of a target. I wasn't extra adventurous and exercised caution and still had a lot of fun and experiences to share.

11. Eat from reputable places. If you get any diarrhea, it's because of something you ate. Unless you want to have constant diarrhea, try not to eat off the street albeit very tempting all the time (I see lots of fresh pineapple on the street). If you cook anything long enough and hot enough, it should be safe to eat. Re: fruit and veggies, if you can't boil it or peel it, don't eat it! Avoid ice unless you know where it came from (i.e. made from bottled water). Don't ever drink the tap water. The locals don't drink it. You shouldn't drink it. Brush your teeth with bottled water. Bring ciprofloxacin +/- metronidazole and PeptoBismol just in case you need it.

12. USD. Bring the most newest $100 and $50 USD available to you. Bring what you think you need and plus a quite a bit more. Nigeria is a cash economy and don't think that you can go to some ATM and withdrawal money unless you want to pay Western Union fees. You get the best exchange rates for $50 and $100 USD bills (not as good for $20 USD) and make sure they are the most current/new versions. Be prepared to exchange your money in a somewhat shady private set up or on the street in Lagos. You get the best rates this way. Currency exchanges and hotels give you lower rates.

13. Anything you would miss not having. If there is some type of shampoo or toothpaste or facial wash that you use regularly and would miss using, bring it with you. Don't expect that you will find it (you might or might not) and it might be somewhat inconvenient and expensive to locate it. Bring your contact lenses solutions too; I don't think I saw any while I was here. You will feel more comfortable having it with you. Trust me.

14. Food. Bring some food with you to make your transition smoother. I brought Luna/Cliff bars and fruit leathers. I wish I brought more. To just pick up some food on your way here and there isn't as convenient in Nigeria as it is back home. Plus, you may need to prepare some meals on your own esp if you are in Nigeria for a while. It was helpful to have some food in my pocket/purse esp when in the hospital after I realized people did not break regularly for lunch.

15. Plan to get a temporary cell phone during your stay. If you will be in Nigeria for a while, a cell phone is key for ppl to find you and for you to find ppl. If you have an unlocked phone in the US, bring it with you and buy a SIM card when you land. Don’t forget the charger and an adapter. Airtel is one of the cheapest and most affordable networks; all networks have somewhat unreliable service. You buy different increments of phone credits to recharge your phone with money to call. Receiving calls and texts are free. You only get charge for the texts you send and the call you initiate. You can also use the phone to call home pretty affordably. Skype is also a good alternative to call home but also may not work if the internet is down (or you don’t have regular access) and if the light is out.

Day 25: First Impressions of Health Care in Lagos & Fela!

Day 25 didn't start off well as I had woken up delirious at 4 am wondering if I was hallucinating or actually I was hearing really loud blaring Yoruba music (the latter). I struggled to fall asleep for the next 3 hours and when I woke to my alarm at 7 AM, the music had stopped. I think the neighbors next to the hotel were entertaining? Whenever I mentioned this incident to anyone, they all laugh and say "Nigerians!". Goodness gracious. Seriously? I woke up with a raging headache and a lousy mood.

In the morning, I was going to go to the medical emergency room at LASUTH to get some additional experience as my time in Lagos was very limited. Monday (Day 25) was considered a national holiday because of Easter and Tuesday was curfew for the governor elections and no movement was allowed between 8 AM to 4/5 PM except to vote. Despite just being in the ED for a brief time (due to my raging headache), I could get a sense that the struggles in Ibadan seemed to be struggles in Lagos. Financial issues seemed to still play a role though a certain portion of the public have "insurance' coverage in Lagos. Poor ventilation and overcrowding was evident even though today was a holiday. They told me that the hallway leading to the 2 consultation rooms for ED visits would be filled with pts lining up or in stretchers or wheelchairs.

Here is a consultation room. There are only 2 rooms to intake patients coming into the ED.

Whereas in Ibadan, there was a consultant in charge of the ED (but didn't see/staff all the patients), there was no dedicated consultant in charge of the ED at LASUTH. The physicians seeing patients today were trainees that had completed their house officer year and year of service to Nigeria. They hadn't entered a residency program yet nor did they have specialized training in emergency medicine. This was not dissimilar to Ibadan.

In the ED grounds, there is a men and women ward for the critical cases of which they are admitted to a medicine service. There is also a resuscitation room for the most critically ill. The medicine service will round on these patients in the emergency ward and the patients will remain in the emergency ward until they are deemed stable enough to go to the floor because the nursing ratio and care was so much better in the ED. I found some irony in this.

The wards consisted of one large room for men and women without drapes, maybe about 15-18 patients in each room. I met a senior registrar in dermatology who was very nice and she told me that yet again, the medicine consultants only round twice a week. The overwhelming mentality among consultants is that I'm higher up, why do I have to work every day?

There were a variety of signs in Ibadan that offered phone numbers to call with any complaints. Similarly, LASUTH had this as well. If you need to speak to the chief medical director any time of day, you can give them a call!


On my way out of the emergency room, a car pulled up with many concerned family members and a woman in the backseat that was clearly unwell and altered. I watched for a bit to see what would happen and by the time my driver had come to pick me up, the woman was not taken in and one of her family members was close to tears. Perhaps the delays were due to money, I'm not sure.

I walked around to take pictures of the campus. First, I was granted permission by the administrator on duty and then he reconsidered and asked me to stop.

Here is the medical emergency ward.


Here is the state of the art technology and diagnostic center that could be anywhere in the world that I mentioned earlier. I'll take pictures of the inside before I leave.


Upon returning back to the hotel, I promptly went to sleep for another few hours. Nathan had the same problem but didn't fall asleep until after 6 AM. I can only hope this Yoruba music is not a daily occurrence. Later, Nathan suggested that we check out Fela!, a Broadway show produced by Jay-Z and Jada and Will Smith that finished its run in NYC earlier this year (won some Tonys too!) and was the first Broadway show to tour Africa and with good reason. Fela Kuti was a Nigerian musician, pioneer of Afrobeat, and human rights activist who through his music and philosophy challenged the corrupt Nigerian government and politics. He had passed away in 1997 due to AIDS.

I knew little of Fela! but thought I might of heard something about it (given Jay-Z et al being involved). We tried to get the cheap seats (5000 Naira) but ended up getting the 10000 Naira seats that remained available. The show was originally scheduled to start at 7 PM (and start 8:40 PM due to African time) but because of the 10 PM curfew (the night before election), the show was to start at 5 PM. Well, not really 5 PM because when we arrived at 6:15 PM (due to delays in transportation, our driver wasn't allowed to take the new Toyota Camry to where the show was because of a lot of car theft around the area), the show had just started for a couple of minutes. We couldn't figure out where our legitimate seats were and the ushers told us just to sit anywhere so we got a pretty good view.

What can I say? The singing and dancing show was rocking! I have such new found appreciation for Afrobeat and for what Fela stood for. Had I wanted Fela! in the US, I would have had little understanding and context. However, being in Nigeria for almost 1 month has given me background and perspective on what his lyrics and music means to Nigeria. I could tell at the audience was very engaged and sang along. Nathan, who hung out with the cast a few nights before at a club, said the cast (they are the original Broadway cast) was so affected by these performances in Lagos as the stories they were telling in the show had such personal meaning and significance to Nigerians. The first Shrine was opened by Fela in Lagos!

There was the raunchy "clock" dance and the Zombie song that made a political statement about the Nigerian soldiers. Because of the Zombie song, which he played in concert in Accra, Ghana, riots broke out and he was banned from going to Ghana. In the show, he talks about how to wishes to leave Nigeria and wants to get consent from his mother, a human rights activists killed by the Nigerian government. However, in his life and his arguments led him to stay in Nigeria until his death.

During intermission, there was an announcement to please stay in our seats because the Vice President of Ghana was going to give some remarks. True to Nigerian form, people wandered here and there. The Vice President of Ghana gave very nice remarks as expected from a politician and commended Lagos State and the other organizers for bringing Fela! to Nigeria. He too personally was a huge Fela fan and had stated he hoped to bring Fela to Accra, Ghana for Ghanaians to enjoy as well, a major deal given how Fela was banned for causing riots in the 1980s! He also commend the Nigerians on a peaceful and transparent election thus far and encouraged them to continue to do so tomorrow for the governor’s election. The person that introduced the Vice President then made mention of Lagos State elected politicians which led to a tense moment with lots of booing. Guess the crowded didn’t like who got elected.

It was special to see Fela! where it all started and to feel the energy and appreciation of the audience. Afterwards, since it was their last show in Lagos before going to Amsterdam, the cast basically continued to sing and dance on stage. We were told not to take pictures earlier but that entirely went out of the window as everyone was recording the impromptu concert given by Fela's youngest son, Seun Kuti!

Here are some pictures:

Part of the set and the big screen to project the show to those in the bleacher seats.

Sahr Ngaujah who is of Sierra Leonean descent played Fela. The woman on the left played Funmilayo, Fela's mother. The other women in the background are Fela's women (he married a lot of women) and dancers.

Sahr Ngaujah is in white and next to him is Seun Kuti, Fela's youngest son who continues to perform with Fela's band.

My day didn't start out that great but ended on such a nice note. Our driver (who we hired for the night since our other driver couldn't take our new car for fear of theft) got us home safely and before the 10 PM curfew to boot. Nathan told me how The Shrine in Chicago has African nights. I think I might have to go check it out next time (just kidding.... sort of).

I ended the night seeing a cockroach in the bathroom. Of course. At least I'm going home this Saturday!