Day 11: In the Bush

I left for Igbo Ora a little before 8 AM which is a rural community about 2 hours outside of Ibadan. Nigerians call the rural communities “the bush”. Igbo Ora has the distinction of being the twin capital of the world! Dr. Fasasi who is a senior family resident was on his way to report for duty this week and was kind to give me a ride. We stopped by his home to pick up a plate, fork and knife and I got to meet his two boys who were very wide eye and sweet – they sang a song for me and told me that they had seen an oyibo once before at school.

We enjoyed a relatively uneventful car ride over as he encouraged me to take pictures at the small towns that we passed (he said, don’t worry, no one will get mad – he was right!). We listened to Michael Jackson and R Kelly on the way there. The roads were awful with many large gaping potholes due to poor maintenance and lack of repairs. We also passed some security checkpoints where one security guard was blatantly asking Dr. Fasasi for a bribe (Dr. Fasasi didn’t relent and drove off). He said I should take a picture of the security guards – I laughed. I wasn’t going to do that – they carried machine guns!

Here is what I saw on our drive there




We got to the rural hospital that is supported by UCH and the state and local government.


This is the clinic.


Yes, there are random goats wandering around (they are like dogs around here except people eat them at some point).

This was my quarters for the next two nights – considered one of the best available in the area.

Here’s the living area.


Here’s the shower where you shower with bucket. No water from the tap here… in a very long time.


There is a separate room for the toilet too. No flushing – you need to pour a big bucket of water to flush it. Apparently, this community does not habit using toilets – they void near trees and in the trenches. I am now pretty good at flushing with a bucket and grateful to have a toilet.

The gent is only on for 4 hrs a day 7 pm to 11 pm. They rarely have any electricity in general at baseline. Otherwise, we rely on battery power or kerosene to cook. Fans only between 7 pm to 11 pm otherwise, we are all just sweating, seeking shade and enjoying ever slightest breeze (thus sometimes showering multiple times a day). Once the gent turned on, we all promptly started charging our battery operated devices.

I stayed with Dr. Sanwo who is also a senior family resident. She was very generous to have me sleep in the bed (she slept on a mattress in the living room) and helped me rig up the bednet. We weren’t sure if mosquitoes would make it into the quarters (thus placing me at risk of malaria as the mosquitoes that transmit malaria bite at night between dusk and dawn) so I had brought a bednet for safety. Dr. Sanwo had mentioned that at the quarters she stayed at for the first 6 wks, she just had a mattress on the floor and roaches would crawl on her at night. Eeek!


Dr. Sanwo is such a kind soul who, to my delight, enjoys cooking! The head of family medicine wanted to make sure that I was well fed (and not with locally made food in the above pictured facilities) and not subsisting on just snacks during my time here. Dr. Sanwo took this to heart and prepared a lovely meal of eba (starchy, thicker than mash potatoes, made out of cassava) and stew with goat, chicken and snails called ila alasepo. It was so good to have a home cooked meal! I even had a mango (after it was washed in drinking water and salt)! She made a point to make me as comfortable as possible (the residents weren’t all that comfortable as well with the facilities and being away from loved ones). I was so thankful.




At night, we all joined together with 4 other residents including Dr. Sanwo and Dr. Fasasi and a training physician doing her year of service in Igo Bora (she was feeling unwell and being treated for malaria) and we ate together. One thing I noticed again was that they all refer to each other by their last names or doctor so and so – they don’t know each other’s first names! Having light and a fan seemed to bring up everyone’s spirits and we enjoyed a vibrant conversation, spending a good deal of time talking about the surgery we had observed (see below).

Earlier in the day, I participated in a walk-in clinic staffed by three senior family medicine residents and one medical officer doing her year of service to Nigeria. The consultant physicians that had staffed this hospital had been on strike for over 4 months now. Thus, this clinic wouldn’t have really continued without the support and staffing from the family medicine residents.

We saw children and adults and even the elderly – we saw a pt in a 70s. I make mention of this because the life expectancy in Nigeria hovers around 50 years old plus or minus a few years (life expectancy in the US is about 78 years old). I had noticed that they would refer to pts in their 60s as elderly and I just had to share how elderly some of the pts we would take care of on the wards in US. Clinic only lasted a few hours and I of course saw a good deal of presumptive malaria – some confirmed with blood smears but most just a clinical diagnosis. One was even admitted for concern of severe malaria for parenteral antimalarial agents. They treat malaria with artemisinin-combination therapy to combat resistance.

What I noticed again was the lack of immediate attending supervision but it was available is some form as they could have called an attending surgeon who runs a surgical ward 10 minutes down the street. This wasn’t pursued as would you want to ask a surgeon a primary care question? (Loaded question yes from an internal medicine resident.) Patients waited patiently and those that would be sent for tests or medications would return in a bit with their results slips or medications to be reviewed with the physician. Exams were limited but mostly would include looking at conjunctiva and checking BP. Noticably, less patients spoke English to a basic proficiency in this community (thus making me reliant on the resident’s translations) and we even saw a patient from Benin republic where I were able to exchange some few phrases in French. The little bit of French that I knew (that Eddy had taught me for our trip to Paris a few years back) certainly brought a smile to both of us. As he left, he said “Merci, au revoir!”

Later in the day, we observed rural surgery – an exploratory abdominal surgery (= laparotomy) in a 10 year old girl with abdominal pain.

Here is where the surgery took place… the hospital.

Here is a snapshot of the surgery.

Yes, these were the conditions. The surgical equipment was sterilized they told me. The patient was sedated with just ketamine without a protected airway. A local anesthetic was used during the incision. The young girl moaned, a lot. The person assisting with the surgery and the other person assisting with the IVs seemed to have little medical knowledge and experience. The family sat in the operating room. As like the A & E at UCH, no monitors anywhere (UCH only had 1 or 2 functioning monitors in the A & E).

Me and three residents all walked in with our street clothes with cell phones. No scrubs. No masks. We didn’t even wash their hands. I had a bottle of water in the operating room. The waste basket was a box that I later discovered was reused. People of whom I was unclear of their role leaned over the surgical field which is suppose to be sterile.

The room smelled of bowel contents, there was only a fan for ventilation and I started to feel nauseous and weak in my knees. I had to leave.

I didn’t see the remainder of the surgery but the young patient made it though as I saw the next day. She had typhoid intestinal perforation.

To be honest, this was one of the most uncomfortable, frankly horrifying experiences I’ve seen as a US trained physician. I could clearly tell that the surgeon was well trained and qualified (he had operated in the UK and Saudi Arabia) but the degree of sterility as well as professionalism was well below what I have become accustomed to in medical practice. A number of unnecessary unclean individuals were in the operating theatre (= operating room) leaning over the surgical field. The patient was poorly draped. The family saw their daughter’s intestines. The abdomen remained open longer for the surgeon to “teach” and show us and other non medical staff this young patient’s organs. The surgeon even said that if he did this in America, he would be arrested. That’s for damn sure. In fact, he told me to take pictures to show everyone in America.

Operating in a rural, resource limited environment certainly will have its drawbacks and limitations but I feel like in part, the conditions could have been improved. The family could sit outside. We could wear masks and limit the number of non-scrubbed and nonessential individuals in the operating room. In part, the surgeon is able to conduct things in such way as the community does not know of any other way. To give the surgeon credit, his surgery was likely life saving and prevented a catastrophe but it certainly could have been done with better even despite economic constraints.

My first day in Igbo Ora left me to see and reflect on the intense poverty. A man sitting next to me outside the hospital while I waited for the others to be dismissed asked me if I could take him with me when I went home. The day before, the guard sitting in front of the guest house asked me what I what food I was going to give to him. As I sat outside the hospital, waiting, I sat on a bench with other Yoruba women and a child that couldn’t have been older than about 1-1.5 years old. Her mother was in the operating room with her sister who was the patient on the table. She had on a diaper and underwear but was otherwise naked and without footwear. It was evident that she was learning how to walk as she could prop herself up onto her feet and then fall back on her bottom. She crawled throughout the dirt, staring at me with her big eyes. She reached for my feet a few times only to be redirected by the aunties that sat around. She put quite a bunch of dirt in her mouth a few times. We tried to give her a snack (looked like a Cheetos) but she seemed to prefer the rocks. The Yoruba woman started to sing a rhythmic song and we started to clap; the toddler started to imitate us and clap her hands. Her smile was darling. I wish I could have taken a picture. (I asked but wasn’t given permission).

My first day in Igbo Ora was a bit frustrating as it was intensely hot and there was no electricity anywhere and we weren’t going to get any relief until the gent was on from 7 to 11. I was sweating through all layers of my clothing and the coolest place was in the car when the AC was on. Plus, given how I am such a clean freak, the accommodations, despite them being the most comfortable available, were simply put, dirty. But what made this day so much better was the company and generosity of the family medicine residents. So many thanks to them, esp Dr. Sanwo.