Day 24: Eating. Shopping & Seeing Lagos

On Day 24, I had made plans with Mayowa, Sope's nephew that lives and works in Lagos. Mayowa's father is Sope's older brother and this gave me a sense of how old Sope was (though he only looks a few years older than Eddy and I!).

Mayowa had recently finished his undergraduate studies and year of service and was working as an accountant while studying for his licensing exams. Mayowa is younger than my younger twin brothers but in talking to him, I got the sense he was very mature, thoughtful and worldly, having the opportunity to travel quite a bit. He had visited Sope in the US and said that he loved the US but loved Nigeria more. While he aspires to study abroad for an MBA (either Columbia in NYC or INSEAD in France both of which have scholarship programs for Nigerians - he's very resourceful too), he hopes to ultimately return to Nigeria. He spoke of his thoughts on poverty, wealth and corruption in Lagos and Nigeria and how his experiences as a grade school teacher during his year of service in Lagos shaped his perspectives. He even dedicates a portion of his monthly salary and time to volunteer and donate to causes important to him. I was impressed by his maturity and his love for Lagos and Nigeria.

We had lunch at a place nearby called Londoner Restaurant. He got chicken and chips and I got chicken and mushroom pizza. This placed marked the first time in which oyibos almost out numbered the number of Africans in a room! A couple of Asians, a large white party and a large mixed party had come for lunch there as well. I also learned that there are no smoking laws in Lagos (like in Chicago) and some gentleman was smoking indoors. Mayowa likes to frequent this place almost weekly to watch football (= soccer) so I got the sense the place was kind of like a sports bar too. Food in Lagos is not cheap; check out the menu. 154 Naira = 1 USD.


When I had spoke to Mayowa that I would like to go shopping to buy locally made beads, Mayowa said he would take care of it which meant that he asked his girlfriend, Oyinda who we picked up after lunch. Oyinda is currently working as a church camp counselor and while we waited for her, all the children were again looking at me (we were in a less wealthy neighborhood) with even a group of young girls gathering near me. I think one of the girls challenged each other to say hello to me. Even Mayowa noted the gawking. What can I say, I look white!

We ended driving toward a local market and just right outside of the market, there was Hausa men selling handmade, northern Nigerian bracelets and necklaces. I left with quite a bit of items for less than $20 USD. The Hausa man was happy to sell and I was happy too. I had accomplished buying some gifts!

One thing that slowed down our day was the famous Lagos traffic. There was lots and lots of traffic to the point that we bought some coconut chips to eat from a street hawker while waiting. I think for one instance, we moved about 20 feet in 20 minutes. 1 foot per minute. Vehicles and motorbikes were even riding on the "sidewalk."


We stopped by Silverbird Cinemas which is a very new and modern movie theater with shopping and a small mini food court. Doesn't this look like it could be anywhere in the world?


Here is me, Mayowa and his gf Oyinda.

Afterwards, we went to go see Lekki which is like the Beverly Hills of Lagos. There is a privately constructed tollroad because private persons were tired of the bad roads maintained by the Lagos State government. Look at how the road actually has lanes and no potholes!


The tollroad is still under development so the further we go into Lekki, the roads got worse. Although there were was a lot of new development and massive estates and buildings (there is lots and lots of undeveloped but very expensive land), there were still quite a few shacks in contrast. On our drive back from Lekki to GRA where the hotel I am staying at is located (which is also another nice area of Lagos), I got to appreciate how expansive the city limits of Lagos was. Mayowa told me how during the last curfew (the day before an election), he had left work at 4:30 PM in Lekki and he didn't get home to GRA until after 11 PM! Lagos traffic is terrible!

Part of this traffic problem is the lack of effective mass transit. There are some big public buses but most people travel by okadas (= motorbike taxis for hire, not illegal in Lagos, just illegal on highway roads), danfos (privately run buses - see below for an example and their love for Obama!) and other bush taxis. There is also a ton of air pollution in Lagos from all these vehicles and everyone and everybody running a generator to have light.


Thanks to Mayowa and Oyinda (and Sope!) for showing me around!

Day 23: Shopping, Signage, Wealth & Poverty in Lagos

I have to admit I slept pretty well at the Lagos Travel Inn. I had a dinner of roasted chicken and chips (= fries, I indulged), watched some Yoruba dramas and a film with Brittany Murphy and surfed via the free wifi. The power went out a few times and the generator was promptly turned on. Gotta love the gent that I don't have to get up and go out to turn on! The only thing I couldn't figure out was how to adjust the air conditioner. Later, I figured out that I couldn't adjust the settings and only could turn on or turn off the AC. Thus, I slept in long sleeves and long pants tugging on all the blankets all night. Plus, no bugs I could see!

After eating a basic but free breakfast, our driver took us to our new hotel, White House.

Here is my room. I will need to take a picture of the complex itself before leaving.


The room is smaller but more updated. It has been sufficient and pretty comfortable. The lighting is dim (it was so bright at the other place) and there is some silly air freshener that sprays some cocoa butter scent every 20 minutes or so. I wish I could disable that. There is also free wifi plus a work out room that I might check out later this week to get back with the program (I haven't formally exercised in 3+ wks).

Dr. Bode generously took time out of his schedule to give us a very informative and enthusiastic driving tour of Lagos. He seemed to know what every building was and knew he way around quite well, directing our driver where to go. The local roads were pretty well paved (unlike Ibadan in general) and traffic was light (because it wasn't a regular work day). There are both large government buses (like the ones in the US) and lots of commerical/private bus drivers and taxis. Okadas (motorcycle taxis) are illegal in Lagos whereas prevalent in Ibadan. Many more people were wearing helmets on their motorbikes unlike Ibadan where only a few wore helmets.

Here's a picture of the houses/slums on stilts (poor quality because we were driving across the 3rd mainland bridge, the longest bridge in Africa!). Lagos is part marsh and people live on the water.




Here is the tallest concrete building in West Africa, the NECOM House.


The Cathedral Church of Christ, founded in 1867, near the marina.


A public beach of the Atlantic Ocean. We got accosted by random men to buy a variety of things and to ride a horse. Very aggressive and followed us around. The private beaches are chiller and require payment to enjoy. I was told not to sit down at any of the beach seats. Plus, we had a pay someone to "park" even though I think parking is free. I learned this is to avoid having them deface your car.

Here is the ocean at high tide.


Here is me.

Next, we went to a shopping mall on Victoria Island, a ritzy part of town. Traffic of course was terrible though the cars were much more fancy - BMWs, Mercedes, Land Rovers and the like. Just because you have a nice car doesn't mean you actually follow road rules.


This mall was like going to any mall I've been to in the developed world. Air conditioned. Lots of oyibos. There was a Sony store. Fried chicken. Clothing shops. A huge westernized supermarket called Shoprite.




Here is a map of the shopping complex.


I can tell that there is a lot of wealth in Lagos. Things are very costly and expensive here. For example, dinner (rice and fish) cost over $17 USD! Even the local Nigerian food costs more. On the flip side, the beggars and poor are still very poor and very aggressive. I think one young man spent about 5 minutes begging to me outside the car at a stoplight saying he was begging because of the grace of God. This is why Dr. Bode told me and the driver to lock the door the second we got into the car.

Despite the wealth and relatively more order and drivable roads in Nigeria, here are some signs to enjoy.

Don't urinate or dump waste here.


Don't urinate here as well if you can zoom in.


Don't think this house is for sale, beware of 419 scam that originated from Nigeria.


I saw a sign that said street hawking was prohibited and that it would be enforced by the police. Of course, there were street hawkers within 10 feet of the sign. Missed photograph opportunity!

I went to a local clothing market near the marina. I was able to haggle for some Nigerian made shirts for family. I tried to buy a premade dress for me or my mom or mother in law but literally the dresses looked like they could fit 2 of me. Too big!


I didn't end up going clubbing at night and fell asleep. Earlier, Dr. Sola tried to convince me to go as he told me a story about how a couple of years ago, his family was all in Nigeria visiting. His children, in their 20s, when out with their cousins and Dr. Sola and his wife went out with their friends. His children at gotten home at about 3 AM but couldn't get into the house because the parents had the house key and were out until 5 AM. As I said, Nigerians know how to party!

At night, I watched some CNN and the coverage on Nigerian election violence was pretty distorting. The violence has been isolated to the conflicted northern part. The southwest part of Nigeria where Lagos and Ibadan are has been quite peaceful. Even the US State Department issued a travel warning on April 15. Don't worry, I'm quite safe and I'm not one to wandering around alone or at night. We will be having 10 PM curfew on Monday night for the Tuesday governor elections with no movement between 8 AM and 4/5 PM. The governor elections in 2 conflicted northern Nigerian states has been postponed.

Tomorrow, more exploring and shopping (of course)!

Day 22: Hotel Shopping, LASUTH & Country Club in Lagos

Hello from Lagos! Day 22, we left Ibadan to Lagos for a fairly uneventful drive. Here are some pictures from our drive out of Ibadan - a better picture of the red roofs.


I'm always amazed how men and women carry stuff on their heads. Women seem to be able to hold more impressive items more effortlessly.


I was in good company during the drive with several professors from where I work in Chicago and we had quite an animated conversation about the proposed changes in medical education after they had met with administration of UI. The professors' observations where quite in line with my own and the leadership at UI acknowledged many deficiencies and needs for improvement include quality assurance, supervision of teaching residents, accountability of faculty to give lectures (some weren't showing up), continuing medical education for attendings, resident evaluations of faculty and the faults of a broken consumer payer based health care system to undergraduate and graduate medical education. We all had dramatic examples of the above but I felt happy to hear that the leadership was receptive and proactively working on change.

Another thing I learned was that 40-60% of admissions at UCH were due to stroke which is very much contributed by uncontrolled and/or undiagnosed high blood pressure. To get on my preventive soap box for a second, high blood pressure doesn't have any "symptoms" until something really bad happens (stroke, heart attack, heart failure, kidney failure, vision loss) but is a very easy problem to diagnosis and treat quite affordably. What it sounds like is that Ibadan needs a good community outreach program possibly within their churches and mosques (since many attend services very regularly) to screen for high blood pressure (no expense there except to borrow a blood pressure cuff and recruit trained volunteers). Certainly, diagnosing high blood pressure and then providing even a little treatment with very cheap medications would stand to improve the health and reduce the costs and burdens resulting from longstanding, uncontrolled high blood pressure. (Off soap box now)

Before the professors headed to the airport for their flight wearing their new Nigerian attire that was made for them (they were measured for clothing on their first day like I was!), we stopped by the Lagos State University Teaching Hospital (LASUTH), a state government supported hospital that provides, get this, free health care for those 0-12 years old and those 60+ years old! (UCH is a federal government hospital; states run independently similarly as states in the US do). We toured their new technology and lab area which was seriously state of the art. It was built within the last 2 years - clean and spacious with up to date technology and equipment to do lab/chemistry/micro examinations and MRI/CT scans. It was nicer than the hospital where I work at in Chicago! Dr. Sola had wanted us to see the spectrum of health care delivery in Nigeria that is clearly affected by how money is spent by the leadership. I have to say I am quite impressed by the LASUTH and Lagos State government for pulling this off. I almost thought I was in another country given what I had been seeing at UCH for the last 3 weeks. Plus, I learned that the Lagos State governor, in an effort to combat wide spread driving on the wrong side of the road, enacted a law such that if anyone was caught doing this, they would be arrested, taken to a hospital for a psych examination that could take up to 5 days to happen (as what sane person would drive on the wrong side of the road? (answer = Nigerians) and pay a fine. Many props (and laughs) to the governor!

We also toured a medical student hostel which was quite clean and spacious and new on the LASUTH campus. Each student had their own room and there were shared bathroom, kitchen and laundry (no machine, but large buckets) facilities. Water from the tap. Quite modern, well ventilated and maintained. In the future, they hope to have visiting residents and students like myself stay in the hostel. However, as my experience at LASUTH was arranged at the last minute, I will be staying in a hotel for the duration of my stay in Lagos with a driver (yes, I know, a driver!). I also learned that LASUTH had been off strike for the last 4 wks or so... oh well, at least I have the chance to see how things run here.

As I discovered, there wasn't a distinct plan of where I (and Nathan the med student who was joining along for the wknd) would be staying and since I would need to pay for 8 nights of hotel (which would be mostly reimbursed with the institutional funding I had received), I wanted to be cost conscious. I wanted to stay somewhere mid-priced, safe, clean and preferably with a generator (I don't like sitting in the sweltering heat in the dark).

We looked at a few places at about 6000 to 10000 Naira a night ($38-64 USD/night) which I can describe as slightly ghetto (one hotel didn't turn on their gent until 6 PM if the power went out during the day) and pretty dingy. Plus, I just didn't get a good sense of the surroundings despite all of them having a security guard at the gate. We ended up at the Lagos Travel Inn which was like a Holiday Inn/Days Inn level. They had a gent; it appeared clean; free breakfast and wifi on the weekends. Not bad, eh at 17500 Naira/night ($113 USD). Plus it had a TV! Later on, at the suggestion of Sope, we checked out White House, another hotel that was close by in a wealthy neigborhood. It was newer and with a pool and exercise facilities for only 15000 Naira/night ($97 USD) despite the advertised rate being over 30000 Naira/night. We mentioned that someone had told us of the about $100 USD per night and we got it. I think there was some Nigerian connection on the downlow that got us this rate. All in all, we must have spent at least 2 hrs hotel shopping. In the end, one night was to be spent at the Lagos Travel Inn (since we paid for it already) and then we would move to the White House. Our hosts from LASUTH were very kind to cover the hotel and meal expenses for our first two days. How generous the Yoruba are.

Here is my room at the Lagos Travel Inn.


Later that night, we joined Dr. Bode, a medical director at LASUTH, at the Lagos Country Club where he is a lifetime member. I've never been to any country club anywhere so I didn't know what to expect. I have to say the Lagos Country Club is pretty posh with a biometric ID element (you have to scan your finger) and key card scan to just get in. Since Lagos power is worse than Ibadan power, this country club has enough generators to supply electricity to this multi-building country club outfitted with multiple bars, a cooling room (24 hrs air conditioning), badminton, swimming pool, restaurant, ping pong, LCD TVs, basketball court, reception facilities, bowel, cricket, taikwando and lots of other stuff I'm probably missing.

From what I learned, there is a pretty extensive process to join where you need to be referred; there is a three month period where ppl can oppose your attempt to join; if you get through that part, you have to pay a $3000 USD membership fee with probably somewhat regular dues. Once a member dies, their children can continue with the membership. Clearly, only the rich can participate. Dr. Bode frequents the country club a lot as he is a avid ping pong player and from what I can gather, Nigerians love to socialize, dance and gab. Each area (i.e. tennis, ping pong, cricket) have a chairman which their pictures placed in a glass cases (Nigerians also like their glory like Asians). Children are seen running about. The club seemed family oriented but also a way for adult men and women to hang out to a late hour.

Dr. Atendule (I'm butchering the spelling (and pronunciation)) who is a dental surgeon and works with Dr. Bode (and assisted us with our hotel shopping) took us to eat at the club's restaurant. I got some Chinese stir fry noodles and curry chicken on rice. Much better than the Chinese food I had in Ibadan though this might have been influenced by hunger as I hadn't eaten since breakfast and it was now 6 PM. Pretty affordable by Lagos standards.


He also ordered us a Chapman, a non-alcoholic beverage with a type of bitter, which contained ice. I was hesitant to drink this because I was told by several sources to not ingest ice in Africa but I really didn't want to be rude and it tasted quite nice. I was relieved to later find out that the ice at the country club was made from bottled water. Of course, I'm at a country club!

Dr. Bode, while we were hanging out in the country club, conveyed his love of Nigeria and his wishes to stay in Nigeria. Though he has traveled quite a bit and his children are studying abroad in the US and UK, it's the expectation that he and they will all return to Nigeria. He loves his life in Nigeria and doesn't feel that he can get all the personal and social amenities elsewhere, even Houston which apparently has a huge Nigerian community. We talked about power and water and how Nigerians provide this for themselves (if they are financially able to do so) since the government can't seem to get it together yet to do so. My favorite statement from him was that in response to bad roads, you should just get a SUV! No wonder I've seen many Rav4s, Pathfinders, and Land Rovers in Lagos already.

My first impressions of Lagos is that there is the wealthy and they live well. There is also the poor, many of whom I learned are Hausa, an ethnic group from Northern Nigeria. The beggers in Lagos are much more aggressive and persistent (this is why I always lock the car door when I get in). The wealthy live well and some have drivers that are employed at about 20000 Naira/month (less than $200 USD) with often room and board. The wealthy are also very generous hosts and want to make sure everyone is as comfortable as possible. I'm quite fortunate to have a driver during my week here, mostly I think for safety reasons but also to facilitate my ability to get around to see the city. (This will NOT be a common occurrence for future students/residents!)

Now that I was in Lagos, which Sope is much more familiar with, Sope's friend and nephew both gave me a call with offers to show us around. Cool. Dr. Sola was going to have his daughter's boyfriend who lives in Lagos show us around. Nathan is very excited about clubbing. I (if you know me at all) was most thrilled about shopping and eating; not so much on the clubbing. It was also very sweet for some of the friends I had made in Ibadan to call and make sure I made it safely.

Tomorrow, we should start our exploring!

Day 21: Last Thoughts in Ibadan

My last day in Ibadan was pretty busy as I was trying to understand my new plans in Lagos, participate in GI clinic, go buy local art at a gallery in UCH (what a great find!), pack, drop off cloth for clothes for Eddy and I at the tailor and say goodbye to the new friends I had made.

With regards to plans in Lagos, I have found that Nigerians make plans but often times, they are last minute and I'm often among the last to find out. I trust that the plans will come to fruition (and that I will be informed) and that I will be as comfortable and safe as possible. Going to Lagos is exciting as there are more things to do and buy (I can't wait to shop) and going to Nigeria and not spending much time in Lagos would be a shame. So I have to put my type A tendencies aside accept that it will be taken care of and settled soon.

In the morning, I participated in GI clinic, first with the senior registrar and then the consultant who arrived at about 12 PM. Clinic was to start at 10 AM. What can I say - African time. While there was a delay, I went to the art gallery Ayo had told me about. I had stopped by the day before but the owner wasn't there and I felt that the prices were a bit higher for certain pieces than I thought it should be. When I returned, I discovered that the owner as an oyibo too - Sri Lankan. His parents had immigrated to Nigeria and he grew up in Nigeria and spoke excellent Yoruba. He married a Nigerian (she's a senior registrar in family medicine) and teaches art classes in UCH for children in addition to opening an gallery for local artists to sell their work. I ended up purchases 6 different paintings from several local artists for about 9000 Naira (less than $60 USD). The prices that were quoted the day before were wrong; the owner felt bad. I love purchasing local art pieces from where I've been - our home in Chicago tells a story of our travels. The art is packed away (as I'm waiting for my ride to Lagos) but I'll have to post pictures later.

In GI clinic, we saw 2 patients who were medical students that were found to have chronic hepatitis B infections after routine screening for their clinical years. I was happy to learn that most of their clinical work up and tests for this new diagnosis was free; however, it seemed that the viral load for hepatitis B and subsequent treatment (pegylated interferon that costs 20,000 Naira a MONTH out of pocket) was a significant financial hardship for them and others with hepatitis B. One of the medical students seemed not to understand what it meant to have a chronic hepatitis B infection. His girlfriend hadn't been tested yet and his parents were unaware of his diagnosis. We pressed for him to tell them and to have them test. If they were negative, they could be vaccinated to prevent it.

Hepatitis B is a virus that can be spread through ways in which HIV is transmitted. In Nigeria, these viruses can be transmitted through cultural and tribal rites of passage such as markings on the face (which has fallen out of favor), circumcision within the community under non aseptic conditions, and breaks of skin and poor hygiene. One thing I have noticed about patients in Nigeria is that they feel very comfortable removing their shoes in the clinic rooms and walking around barefoot. I've even seen staff walk around the hospital hallways barefooted.

In any case, this medical student really lacked understanding of his diagnosis and what it really meant. What I thought was cool about the consultant was that he said - "come to my office and ask me questions. I will help you understand, eh?" (Nigerians really like to say ehhh.... ahhh... oh.... uh eh! eh eh! to make a point or to show their emphatic agreement to your statement - I (naturally) have started to do this too)

With the senior registrar, we saw a patient that was a professor of UI and the whole clinic encounter was sir this, sir that. Even when a digital rectal exam was being completed, the resident was "sorry sir" and the patient responded" Thank you" or "E se" (thank you in Yoruba). It must have been the most pleasant DRE dialogue I've heard to date. This professor was referred to the GI clinic for consideration of an endoscopy to look inside his stomach for evidence of pernicious anemia. The clinical data didn't really seem to point to this diagnosis in my opinion. What was interesting about the history taking was that it was assumed that the professor didn't smoke or drink because he was a professor (I said professors in the US do both) and that wasn't professor behavior. Plus, he had no idea what his exact age was. He told me how his mother recollected his birth to him and the events surrounding it. He estimated his age to be late 60s say 68. I also recall this happening for another patient I had seen in Igbo Ora as well.

I learned a bit about what things cost. An EGD to look inside the stomach was about 26000 Naira and another 6000 Naira to biopsy a lesion. CT scan was 20000 Naira but a barium enema (which I think is cheaper than a CT in the US) was 30000 Naira. An abdominal xray was about 3000 Naira and an admission to the hospital for a day was 1000 Naira. It's no wonder patients hangout in the hospital with little studies and tests completed.

The last patient of the day was a middle age woman that was very yellow (jaundiced). I could see it in her eyes, the palms and soles of her hands and feet and her skin had a yellow hue. We could palpate her gallbladder very distinctively. She clearly had a biliary/pancreatic malignancy of some sort and was being admitted for further work up. The consultant estimated her bilirubin (the stuff that causes the yellow) to be in the 20-30s.

After clinic, I had made plans with Stella and Maria to finally get to the tailor to get our matching clothes made. We were going to use Dayo's tailor for Eddy's attire. I had to go today as I was leaving Ibadan and the holiday wknd was starting. Our plans to get this done was even rescheduled for today as the day before, they arrived late and I had to go to lecture. Today, African time still held true. We were suppose to leave at 2 PM and ended leaving at 5 PM. But I was happy to make it to the tailor and I'm getting two dresses again. The tailoring fee was cheaper this time, only $3000 Naira for me. $2500 Naira for Eddy. Dayo and Nathan the medical student now here are going to help make sure I get the completed clothes before I leave Nigeria next Saturday.

Before going to the tailor, we went back to this semi-shady-ish money exchange place. I was pretty happy with the offered conversion rate. Nathan, who is Ghanaian, tried to negotiate a higher rate for himself because he had $100 USD bills and I had $50 USD bills. This was not successful and the owner of the money exchange place said that he was generous with my exchange rate because I'm a woman. I bring this up because even though Nathan is African, he hasn't been to Nigeria before. However, every time I bring up something about making sure Nathan is okay, Dayo and others always say - he's a man and an African, he'll figure it out. What I guess is a predominant thought is that you take care of the women (esp the white woman) and the men are left to figure things out.

Since Nathan is Ghanaian, he had some perspectives on how Ghanaians and Nigerians were different (most in part due to inefficiency and infrastructure issues in Nigeria). In the end, my sense of Nigerians (since I've never been to Ghana) is that they are very use to taking care of themselves. They get no electricity from the government, they use a generator. The government can't provide clean water, they dig their own well and buy drinking water. Nigerians are use providing for themselves and their family. They are very resilient in that sense.

Later that night, I made some pasta with Classico sauce and canned vegetables for Nathan and I ate. He added some beef off the grill (suya) that he purchased at the canteen that was wrapped in newspaper. He said the risk of getting diarrhea was worth eating the meat. Must have been really good.

I met with the new friends I had made here and there throughout the day. I would be remiss to say that there were somethings we hadn't had a chance to do yet and somethings they had been able to share with me (i.e. Christianity). We took a few pictures:

Me and Kemi a Nigerian American medical student from Washington DC


Me, Stella and Maria


Me and Dayo

I'll miss the new friends I've made and I have new appreciation and respect for life in Nigeria (and the US). Ibadan was lovely and I'm glad to have called the guesthouse home but it would have been nice for the guesthouse to have a microwave and/or a TV for future guests. Where I will be staying in Lagos (to be determined at this point) may have a TV which is exciting which means I can watch the royal wedding this week!

Day 20: Chest Clinic, Free Food & Lagos

Little did I know that Day 20 would be my last full day working at UCH (more on this later). I started off by going to a resident lead dermatology lecture about bullous lesions (I wasn't very interested) and got called away to participate in Chest clinic with the same consultant that had lead ward rounds the day before.

I hadn't had the best impression of this consultant given our protracted conversation about my religious beliefs on rounds in front of the patient the day before but I have to admit I enjoyed seeing clinic patients with him. Of course, while in clinic, there were several gossiping interludes. However, we did some good work and he was very receptive and curious about my observations and feedback. He even admitted that increased resident supervision would be beneficial and that sometimes he will round on his own on the non consultant rounding days to make sure nothing was being missed.

We saw a 70 year old patient presenting with signs of right heart failure likely due to longstanding emphysema. Here is this man's chest xray. He was a smoker, had TB in the past (MDs - can you tell by the CXR?) and had engorged veins in his neck and swelling of his legs. We talked about optimal therapy and it no longer surprised me that first line medications we use are not necessarily prescribed up front (due to cost), spirometry to evaluate lung function wasn't available in the clinic (in fact the full PFT lab had been closed for a couple of months because the equipment was broken) and that in order for the patient to receive oxygen (which has been proven to extend the life of those with emphysema) he would have to be admitted. There was no such thing as home oxygen.


We also saw a middle aged woman with presented with recurrent hemopytsis (= coughing up blood). She had an episode many years back and now recently had it. It had since resolved.

This was her chest xray 5 years prior.



Here is her chest xray currently.


What we see here are cavitary lesions in both lungs. However, in time, she had developed a fungus ball in her right lung whereas before she only had it in her left lung! Aspergilloma! She had prior history of treated tuberculosis and this type of fungus loves the cavities that TB creates in the lung. I had seen this type of lesion before on CT scan but not so clear and prounounced on a chest xray. This patient we referred to a cardiothoracic surgery to see if she would be a candidate to have the fungus balls resected. We all knew that a major limiting factor would be (as you know by now) - money.

We had another patient that had complete opacification of the right lung, suspicious for fluid and/or mass. We attempted to sample some pleural fluid from the lung (= thoracentesis) with the current supplies that were available. Alcohol to clean the area from a metal bowl. Cotton balls to apply the alcohol. The clinic had a few needles and syringes that were free of cost to the patient. This patient had a bit of adipose (fat) in her back and we needed a longer needle to access the pleural space to get some fluid. We had to write a prescription for this needle; the patient's family member when to go purchase it and then we tried again. This delayed the procedure by about 1 hour. Unfortunately for the patient, the physician had no free lidocaine and he had said that families often balk at buying lidocaine to numb up the area where the needle was going in because of cost. Thus, we had attempted this thoracentesis without lidocaine and I could see that she was in a good deal of discomfort. The consultant said he might go buy some lidocaine himself and use it on patients in the future. This procedure wasn't successful (we didn't get any fluid) and the consultant was suspicious for a mass. We ordered a CT chest for her; hopefully, her family can afford it.

Later in the day, we had an abbreviated ward rounds for one of the visiting professors from where I work in Chicago. The residents presented three of our patients and I very much sensed a high level of deference the residents and consultant had for the visiting professor. This visiting professor is known for his teaching, physical exam and clinical diagnosis and he didn't disappoint. I think it was nice for the residents to see a consultant teach at the bedside in a nurturing, non-adverserial approach. The last patient we saw was basically comatose with a severe neurological lesion - very brisk reflexes and upgoing Babinskis on exam. She had no lumbar puncture and CT head and looked as it death was not far away. The visiting professor and I discussed this case in private later and we were both amazed that this patient had deteriorate to such a clinical condition with such clinical findings. We both knew what was going on and why it was going on.

Following another lecture by the visiting professor on clinical reasoning, there was an outdoor reception for the visiting professors and UCH medical students, residents and consultants. There was free food and drinks so you can be sure the hungry trainees were all around! There were fried donuts, finger sandwiches, pieces of chicken ( a little bit random) and pieces on beef on a toothpick (also a bit random). I was hungry and had some food - no diarrhea illness I'm happy to report!

There was a photographer going around to take pictures. I had noticed a few photographers at a variety of events I had been to over the last few days, esp with the professors from Chicago visiting. I assumed they were part of the university. However, I later learned that they are freelance photographers that take your picture and then ask you for 100 to 200 Naira. Shady, eh?

Here are some pictures from the reception with Dr. Oluwatosi, a surgeon and a friend of Dr. Sola. Dr. Oluwatosi has called on me periodically to make sure I've been doing well.


Here are a couple of the women medicine residents. There are a total of 8 women in a program of 30+.


Most of the residents and medical students that spoke to the visiting professors asked the number 1 question - how can I rotate/work in the US? One medical student even brought out one of our major medical textbooks to have one of the visiting professors autograph it (she wrote a chapter in it). In addition to having someone from "home" to chat with, the arrival of the two visiting professors from Chicago raised the oyibo contingency at UCH by 200%!

Later at night, I received a call from Dr. Sola. The Lagos hospital strike had resolved. Since I was planning on going to play in Lagos for the long weekend (Friday is Good Friday, Monday for Easter and Tuesday is election day), we decided on the fly that it might be a good opportunity for me to rotate next week at the Lagos teaching hospital, provided we could arrange for the clinical experience and accommodations. Plus, Dr. Sola wanted me to see a Nigerian hospital where things were running smoother without as many of the struggles of UCH and tests were available and ordered for patients (not sure how this happens with all the cost issues) so that I could leave with a more complete picture of health care in Nigeria. Thus, tomorrow, Day 21, would be my last day at UCH and we would be off for Lagos on Friday.

Stay tuned!

Day 19: Morning Report, Rounds & University of Ibadan

I'm very behind on blogging now given all the issues with either internet (I was starting to think our provider turned off internet at 8:30 PM every night) and of course power. We're on the gent now and I'm trying to enjoy it before going to bed for the night.

On Day 19, we started off the day with the internal medicine weekly chart review (= morning report) that pretty much started on time. The house officer read a presentation of the case that was distributed in handouts and offered her initial differential. Then came the registrar (= junior resident) who offered his commentary and differential diagnosis. Then finally came the senior registrar (= senior resident) who did the same. In between these long drawn out presentations, the attendings literally attacked the residents on their presentations like a firing squad. Attacked in an uncomfortable, 'I'm so glad I'm not presenting' kind of way... or at least this was how I and the US trained physicians from my institution that were present perceived it to be.

This case presentation was a poor gentleman that came in shock with a likely gastric malignancy developing tumor lysis syndrome and sepsis. In other words, he had cancer and he was dying when he was admitted. It was so striking that the patient did not receive many standards of care that we offer readily in the US. He needed ICU admission. That wasn't even explored because the patient had no money though this didn't stop the attendings from criticizing the residents about this. He hadn't had labs in days because his family couldn't afford it. He didn't get a chest xray from this admission. In this whole account of the patient's clinical course, the residents described all the resident documentation and interventions. Notably missing was transparency of attending accountability and participation. The attendings were quick to judge and eviscerate the residents; the supervising attending on this case wasn't even around I think. One of the professors from where I work in Chicago (they are visiting) even tried to diffuse the situation and make the discussion more constructive and educational which was quickly dismissed by another attending who said this part of the review was specifically geared so the residents could defend themselves.

In the end, everyone's thoughts on all levels on the possible diagnosis and mechanism of death were pretty consistent and the most redeeming element of this experience was that the patient had an autopsy at death. The findings on autopsy were reviewed and presented. An autopsy at death is a way for physicians to really find out what happened versus what they think happened. In a setting where often times many studies/labs are not completed, I think this component is incredibly important in medical education in Nigeria as it truly provides actual data to understand what had developed in the patient and what ultimately lead to death. In the senior registrar's presentation, he made mention of the studies and labs that should have been completed should the money have been available. I'm just amazed - How can resident physicians and medical students receive well-rounded medical education with these limitations in seeing how a specific condition or complaint is worked up and understood when most of the time, labs and tests and imaging can't be completed?

Following the chart review, the residents wanted to get my impressions. I said it was interesting and very different from how we run our morning reports and how we focus on learning points (and not defending ourselves). The most crazy thing about this whole experience was that all the residents I spoke to thought this experience was very educational. I guess they have come to accept and expect this type of teaching and behavior.

Afterwards, I participated in the Chest unit consultant (= attending) ward rounds. If I thought the senior registrar's rounds was slow the day before, the consultant rounds was even slower with 2 less patients. There was some teaching involved (we discussed the pathophysiology of pulmonary edema (= fluid filled lungs)) but there was even more gossiping and getting off topic that sidetracked us from rounds. I think we even spent about 5 (too many) minutes on rounds dedicated to discussing my religious preferences and why I wasn't a Christian.... in front of the patient. I felt bad.

The consultant spoke very quickly and with a stammer. The residents in private admitted that they often times missed what the consultant said and I often times had to ask him to repeat things when he asked me questions. Generally, I am able to communicate well in English with Nigerians but I find if I'm not paying attention or if they speak real fast, I will miss everything they say. On the flipside, a few Nigerians have said that I speak too fast (just like an American) and that I should slow down. Thus, I've been trying to slow down my speech and spend time on my greetings and asking how people are doing which is very important in Nigerian culture.

In any case, on rounds, we saw the same patients and I must report that not much progress had been made since yesterday. The obtunded patients that need CT scans of their heads and/or sampling of cerebospinal fluid like ASAP (or even weeks before) did not get them. One patient had expired and one patient, despite our efforts to increase his water pill, remained essentially unchanged and volume overloaded if not more volume overloaded. We have a patient with HIV/AIDS that was thought to have a space occupying brain lesion and was obtunded and unresponsive with a new large mass growing on her shoulder. Presentations of disease in Nigeria are so advanced and clinically apparent.

We had a patient that had needed a hematocrit (PCV they call here) for several days and the team wasn't sure if the family could afford it (PCV costs 200 Naira = $1.30 USD). In the end, the patient had the PCV done but if the family couldn't afford it, the residents were going to pay for it. The residents mentioned to me that sometimes when the patient is in a real bind (and really needs the test) and/or the test is quite inexpensive, the residents will pay for the test (i.e. 200 Naira for the PCV) or pool money together to get the medication/supply/imaging for the patient. Talk about blurring the lines between the doctor and patient relationship.

One other thing I learned was that frequently when patient needs tests but can't afford it, the team orders a social worker consult. They order this consult like how I order physical therapy on all my elderly patients. The social worker makes a home visit to the patient's home to find family members to persaude them to get (or find) enough money to pay for health care. Often times, from what I hear, the social workers discover what the residents suspected all along - no money anywhere. There is just a little pool of charity money to go around, maybe just a few hundred Naira per patient here and there.

I think my lack of good sleep (since starting mefloquine) plus eating less than I'm use to eating in a hot and humid environment is starting to take its toll on me. On rounds, I was starting to feel faint to the point they wanted to excuse me but I ate a bit of a Luna bar and drank some water (I carry a bottle around every day), saw 3 more patients (albeit slowly as per above) and was so thankful to eat this lunch.


As it turns out, one of the medicine senior registrar's just passed his part 2 of his fellowship exam and was now a consultant! He provided boxed lunches and beverage for all his colleagues. The residents were very kind to offer me lunch and I just couldn't refuse as I thought I was going to pass out soon. The lunch had two types of rice (one spicy), a piece of chicken, a piece of beef (which I gave away by the time I took this picture) and moin moin (my new favorite Nigerian food). I washed most of this box lunched down with a Coke. One thing in the world that is very consistent I must say is Coke.

After listening to one of the Chicago professor's keynote speech on medical education (which was met with a lot of interest; a medical student who asked a question at the end expressed so much enthusiasm and hope for the opportunities for collaboration that were discussed), Ayo took me to the main non medical campus of the University of Ibadan (UI), the oldest and most prestigious university in Nigeria. Ayo and his wife, who is a lecturer in sociology at UI, live on the campus in subsizided housing for 5000 Naira a month. What a great deal!


They drove me around the UI campus of which the grounds use to be a forest. Thus, lots and lots of trees. Maybe I was imagining things, but I truly thought the air quality was better. The campus is seriously like an gated community with housing, a small market, small health clinic, hostel, exercise facilities, elementary to high school, and even a bank. A self contained little town. What was really nice was the peace and quiet. Granted, there is probably some noise once the generators are turned on, but from what I could tell, there was an absence of honking, yelling and riff raft that is elsewhere. UCH is pretty quiet too but I have to admit that I have some loud neighbors.

We got there too late to see the botanical gardens and zoo (yes, also within the campus) but hopefully before I can visit before I leave. Ayo and his wife Funke were so kind to welcome me into their home. I got to see their simple but homey place. It was so nice to see Ayo and Funke together. They complimented each other so well. It just made me miss my husband.


On the drive back to UCH to drop me off, a young child walked up our car to beg in Yoruba while we were at a stop light. Ayo engaged in a conversation with the child who could be no older than 8 asking him why he was begging and not going to school. Ayo said the young child had no good answer.

Ayo also mentioned to me that the southern part of Nigeria (where Ibadan and Lagos are located) are considered to be significantly more developed and educated than the northern part of Nigeria. He did his year of service in one of those communities and for the whole year, he had NO POWER. For one whole year. He only spoke to his mother once every 3 months. The nearest phone was an hour away. He also shared how its common practice for families in the north to at a certain age, kick out their children to start begging as parents could not longer afford to feed them. I asked about why have so many children if you can't feed them. The answer was that in part it was due to lack of education resulting in lack of understanding of family planning but primarily, this was how they lived. From his perspective, many Nigerians don't believe that health, water, electricity and education are a right in any way. He also said Nigerians pray a lot and have a lot of faith because they can't afford to have anything bad happen to them with so many things going awry already.

We discussed the election results (the incumbent president won). Although this might not have been his desired result, he was happy that the elections had happened peacefully and potentially giving Nigeria legitimacy to the world as an evolving democracy. Yes, I agreed - a step in the right direction. But please tell me, first on the agenda, is to fix electricity problem ASAP, right??

Day 18: Internal Medicine, Poverty & Religion

Day 18 was the day I started my internal medicine posting (= rotation) and less than 2 wks before I return to Chicago! I’m in a nice rhythm of things at UCH – I sort of know my way around and recognize people while I’m in the hospital. I know where to get phone credits and I’m just about finally acclimated to the daily interruptions in power. I’m use to eating my carb heavy diet with a daily egg or two for protein and despite lots of carbs, I think I’ve lost some weight probably from all the sweating I’ve been doing. I’ve told Eddy that I want fresh fruit and Piece pizza and salad upon arrival home, in the airport if at all possible.

Today, 2 professors from the medical school where I train arrived for their weeklong visit to share innovations in medical education. From speaking to them and the fourth year med student from Chicago (who is originally from Ghana) that just arrived for a 2 wk elective in radiation oncology, I now get the sense that I am the more experienced and wise visitor in Nigeria. As I described the power outages and adaptations I have learned to adjust to the variety of things that can happen in a day, I could sense their confusion and apprehension. Don’t worry – the amenities in UCH are quite posh in comparison to elsewhere (i.e. the bush) and we have had pretty consistent light for a while.

What I’ve learned about internal medicine and family medicine at UCH is that family medicine is a strictly outpatient practice and solely provide the primary care to UCH patients. Family medicine residents do rotate in pediatrics, internal medicine and OBGYN wards and when any of their patients require admission into the hospital, they get admitted to one of the above services. Thus, the type of power struggles and not wanting to step on each other feet that I’ve experienced in the US does definitely happen between family medicine and internal medicine.

Internal medicine wards are divided by specialty – Chest (= Pulmonary), GI/Liver, Neurology, Dermatology, Endocrinology and Cardiology and they each have outpatient clinics once to twice a week. However, internal medicine doesn’t provide any primary care at UCH unlike where I work where general internal medicine (including the residents) provides the primary care as we have no significant family medicine practice. Another difference I noted right away was that there are only a handful of women in the internal medicine residency program as opposed to almost half of the family medicine program who we women. As women marry and have children (an ingrained cultural expectation), family medicine, given its outpatient nature, is felt to lend to a lifestyle where one can bear and raise children. One of the woman internal medicine residents had described internal medicine as more stressful with longer hours. Surgery is worse with only 1 woman in the program at UCH.

Today, I attended senior registrar (= senior resident) ward rounds in the Chest unit with his team of house officers (= interns) and registrars (= junior residents). I was struck to learn that the consultant (= attending) only rounds with the team twice a week. Yes, only twice a week. The senior registrar rounds with the team at least once a week. The registrars see the patients they are following at least 3 times a week and the house officer sees the patient daily and writes notes or transcribes them form the consultant or senior registrar. It seems like within levels of the hierarchy, there is some degree of communication on a daily basis esp if a patient is going to be sent home. However, even the residents acknowledge lapses in communication and supervision. Sometimes, I hear the consultant even refuses or is MIA for the twice a week rounds. Seriously?

During rounds, we saw a service of 14 patients, many of who had complications from tuberculosis – someone with right heart failure from chronic lung disease due to tuberculosis who was volume overloaded (= body backed up with water), a young woman with a dropped lung (= pneumothorax) and a couple of men with a lung filled with pus (= empyema). A common theme was that due to financial constraints of the patients, most had only a chest xray but none had a CT scan of the chest to better look at the lungs. Sadly, I learned that a CT scan costs 40,000 Naira which only is a little over $250 USD but the minimum wage in Nigeria (that isn’t widely adhered to) is only 18,000 Naira a month. Thus, poverty, sickness and even death all are very much intertwined and determine health outcomes in Nigeria.

In a hospital in the US, when doctors order tests or labs or medications for patients, a process is initiated to get that test completed, lab drawn and medication shipped up to the floor and administered to the patient. Here, if physicians would like to order any test/lab/medication, they write a prescription or on a random little slip of paper a specific order and the patient’s family needs to pay for the test or lab or go to a pharmacy nearby to pick up the medication and bring it back to the nurse to be administered. (Can you even imagine patients in the US doing this?) Thus, the senior registrar was telling me how there were lots of problems of fake medications as many families seek to purchase medications outside of the UCH due to cost. In some cases, family place a deposit down for the patient and the medication can be directly ordered from the UCH pharmacy and the cost is deducted from deposit. In this situation, the quality and authencity of the medication can be confirmed. This made me wonder if one of the patients that had purchased a water pill to remove fluid was even really getting the water pill.

We also saw a few HIV patients that we referred to as retroviral patients with pulmonary issues and a few stroke patients that due to service politics (similar to where I work) led the patient to stay on the Chest service and not be transferred to say the Neurology service which would likely be more appropriate (they didn’t transfer because they couldn’t get head CT due to financial constraints). One stroke patient we discussed quite a bit was a 50 some year old man that had a catastrophic stroke 7 days before. He had not regained consciousness, was unresponsive and showing signs that he was becoming infected (= septic). His family was poor and had no money and since his transfer to UCH, nothing with exception to supportive care (IV fluids, oxygen) plus a little antibiotic (ceftriaxone I believe, family couldn’t afford Flagyl as well). I was curious to see how much the family understood had happen and whether the medical team had discussed his overall guarded prognosis. I guess what I learned was not surprising as the medical team had not had these conversations in part due to cultural and religious factors.

In Nigeria, the literacy and education level is very low, particularly among young women. This translates to low health literacy and poor understanding to family planning (which is another topic for another time). As such, the residents feel that despite their best efforts to discuss what was going on would be met with much confusion and lack of understanding. It’s not uncommon for family members that round up enough money for a CT scan to think that the CT scan is a treatment and not just a purely diagnostic tool to guide treatment. Furthermore, as I have eluded to in prior posts, Nigerians are overwhelmingly religious. Whenever I discuss reliability of power, reduction of corruption, improvement of education, clean water for all, Nigerians almost all say that they pray for these things to happen as in light of their daily hardships, their faith is what carries them through each day. I’ve come to think of Nigerians are very resilient and faithful individuals. Given this religious context, to even broach the topic of palliative care or hospice or even to give warning for a very poor outcome may be interpreted as the physicians giving up and being “a devil”. It was painful to learn about the clinical course of the 50 some year old man that had a catastrophic stroke and was actively dying (in my opinion) in part given that no substantial medical intervention had been occurring due to poverty. The next day, I had learned that he had passed away over night. Poverty sucks.

Another notable thing was that patients need to purchase gloves to provide to the physicians to exam them. (If I had known this before I came, I would have brought with me boxes and boxes of gloves with me.) For whatever reason, possibly due to the lack of running water to wash hands, the residents have grown accustomed to examining patients with gloves and due to (again) financial constraints, often only the senior registrar was the only one examining the patient while the others stood around and observed. Not necessarily ideal for hands on learning. One thing the senior registrar did an excellent job was patient modesty in terms of drawing the curtains surrounding the patient’s bed to give them privacy during the physician exam.

Our rounds were sort of slow as we often got derailed by random gossiping and topics. I was contributing to this for a while but then I started to feel bad as we were having these conversations in front of the patients in the middle of our evaluation of them. Later, as I observed, this was a standard that was deemed acceptable from the top down from the attendings. I did quietly say something to the senior registrar and what I think resonated most with him was that despite any poor role modeling that may be occurring, we as residents know what the standard should be (all the residents agreed that we probably shouldn’t be gossiping in front of patients) and we should strive to meet these standards. I get a sense at the residents feel overworked, under appreciated, abused (I later saw this the next day), underfed (internal medicine residents barely eat as well) and working with too much independence and too little supervision for their level of training.

We also talked about obesity as of course the common thought is that American patients are quite obese. I couldn’t refute that. In Nigeria, I had seen far fewer obese patients. In fact, obesity in Nigeria is something people are often proud of as it means that they are well off and have enough to eat. However, on the flip side, the residents acknowledge that they had been starting to see more diabetes and heart attacks that are definitely contributed by obesity.

Later in the day, one of the professors from Chicago where I worked gave a pretty interesting talk on clinical reasoning and how we might teach trainees how to think like doctors as the process of how we come to diagnosis something is often not organize and fraught with error. Before this talk, I again spoke more Chinese! I too was got off guard by this. A visiting medical student that was Nigerian by birth, educated in Ghana and was attending medical school in Najing, China due to unknown reasons by me knew a bit a Mandarin after living in China for the last 5 years. Speaking a bit a Chinese with him was kind of cool at first until I started to get the sense that he wanted to know me better so that I could him to get to the US. Of course, we again had that conversation about how I wasn’t really American because I must be some Asian.

In other things, I’ve finally succeed in taking a picture of a hospital ward! Hospital wards are separated by gender and are mixed in terms of what service they are admitted under. Wards vary in size with as little as 14 patients in a room up to over 30 patients in one room.

Here is a men’s ward with over 30 patients. They are separated by curtains and each bed has a bed net for the evening. See the different teams rounding.

Will catch up tomorrow. Goodnight!