Day 7: Malaria, Graduate Medical Education and National Health Insurance in Nigeria

Today, I learned a bit about the Nigerian National Health Insurance Scheme (NHIS) that exists. A few citizens including governmental workers are covered by the NHIS that was started in 1999. It provides insurance coverage for visits and subsidized tests/studies and medications. I guess my prior statement that here is no health insurance in Nigeria wasn't entirely correct but it doesn't seem like NHIS isn't particularly comprehensive or inclusive. However, it is a start.

I saw patients today with a training physician that is doing her year of service. We saw lots of osteoarthritis, high blood pressure and diabetes which I definitely felt that I could contribute in a productive way. The trade names were different but there were a lot of patients on amlodipine, lisinopril and HCTZ. There were also a lot patients on methyldopa which we don't use frequently in the US. I had a chance to counsel a gentleman regarding his blood pressure which was high despite being on 3 medications. We discussed exercise vs increasing a medication at this visit which made me feel right at home; in the end, he was like most patients I have in Chicago, he wished to try a trial of exercise and lifestyle modification to see if it improved his blood pressure before increasing his lisinopril. We also saw a patient that basically had reflux disease. Whereas I may lean towards lifestyle modification, it seems that Nigerians, like the Taiwanese where I have done a medical rotation, prefer to leave the doctor with a new medication to treat the issue. I also spent a good amount of time explaining osteoarthritis to patient who desired a medication to treat his arthritis. In the end, I think I was able to convey osteoarthritis as a condition by drawing a metaphor to how cars get older and things start to break down a bit.

We also saw presumed malaria. For me, malaria still has a nice mystique to it given I've only seen it twice before coming to Nigeria and the only people that get it in US are travelers returning from their visits in malaria ridden parts of the world that foolishly decided not to take malaria prophylaxis. Here, it's common. It's like getting a cold. Everyone has had it before and has been treated for it. Everyone that comes in with fever +/- body aches +/- headache and other symptoms was presumed to have malaria. Since cost is a driving force in how and what level of care is obtained, many times, patients are just treated empirically for malaria without a blood smear to look for the parasites in the red blood cells. Patients commonly request this because it's more cost efficient. In the US, a person with malaria is in the ICU! In the afternoon, I stopped by the General Outpatient Practice Laboratory where a technician showed me blood smears and I saw lots and lots of plasmodium parasites which cause malaria. In the NHIS clinic, we saw a patient who had a recent fever and fatigue. We sent her home with some anti-malarials just like I would send someone home with instructions to rest and drink lots of fluids for a cold.

During the whole time in the NHIS clinic, it was apparent that attending supervision may be available but not readily and actively used. In the US, all training physicians that see any and all patients must discuss the case with an attending physician and ultimately, any medical documentation is co-signed by the attending. In some scenarios, the attendings also see and examine the patient but this is not required in all settings. From my time here, I've noticed that though attendings state that they supervise the training physicians, for the most part, it is quite passive. The training physician I worked with this morning didn't staff any of the patients she saw with an attending and the attending didn't see any of the patients that had come to the clinic in the morning. In fact, this training physician elected to make a more conservative medication change as she knew it would be difficult and a bit challenging to locate an attending to discuss any more extreme medication modification. In speaking with more residents, some find this a bit disconcerting as they desire more mentorship, supervision, teaching and guidance in making medical decisions. Today, I was helping a physician with just 1 year of post graduate medical training that was basically seeing patients as an independent practitioner.

I have to admit, though I'm getting use to being in Nigeria, I do miss my husband, family and friends and life at home in Chicago. And just when I'm about to wallow about how I miss the US, I get a surprise visit from some visitors that brighten my day. Today, two very nice women, Stella and Maria, from the breast cancer research lab stopped by the say hello. They extended an invitation for me to visit them in their homes and they discussed how they wanted to me get more cloth to make matching clothes for Eddy and I. Apparently, it is a Nigerian practice for husband and wife to dress in matching fabric to social events, to church and on the weekend when they are off work. When I inquired about this with Dayo, he said "of course, we wear the same fabric to church!". We'll have to see if Eddy will want us to go out wearing the same fabric, let alone Nigerian attire, in Chicago.

I've included some pictures below of UCH. It was a bit of an ordeal to get these pictures taken. I had to ask the security guards who said it was okay and then a woman who was walking around told me I had to stop and then I had to ask the Chief Medical Director (who I had met with earlier in the day) if it was okay. Then I had to trouble the Chief Medical Director to inform the guards that is was okay and then one of the guards followed me around and finally, when I wanted to take a picture of the front gate, I had to speak to the guard supervisor. After all this and prior more minor incidents, I discovered this concern regarding picture taking was because I was a oyibo. There is a concern and fear that oyibos will take pictures and then portray Nigerians in the media and abroad in a poor light. Dayo said that next time we are outside UCH, he will take pictures for me of the traffic and buildings as if I was to try to take pictures, it would most certainly be met with some yelling.

The view walking in.


To the right of the picture above. The same buildings also exist on the left side. Each floor is for something different - surgery, medicine, pediatrics.


The view when you drive or walk into the complex. There is security who write down license plates and on your way out, they have you open the trunk to make sure nothing is in there.