Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 1, 2003, pp. 44-46

Indian Journal of Surgery, Vol. 65, No. 1, Jan.-Feb. 2003, pp. 44-46

Perspectives of Rural Surgeons

Rural Surgery in Nigeria

O. A. Awojobi

Awojobi Clinic Eruwa, P O Box 5, Eruwa, Oyo State, Nigeria.
Address for correspondence: Dr O. A. Awojobi, Awojobi clinic Eruwa, P O Box 5, Eruwa, Oyo State, Nigeria. Email: oluyombo@hotmail.com

Paper received: June 2002
Paper accepted: September 2002

Code Number: is03008

INTRODUCTION

The Faculty of Medicine, University of Ibadan, Ibadan, Nigeria and the government of Western Nigeria set an example in primary health care delivery 15 years ahead of the World Health Organisation's Alma Ata Declaration on the same subject when they established the Ibarapa Community Health Project in 1963.¹ The programme is based at the Rural Health Centre (now a General Hospital) in Igbo-ora, the largest of the seven towns in rural Ibarapa district.

However, the surgical component of the service became evident only in 1983 (20 years after its inception) when an alumnus of the University took up an appointment in the district.^{2, 3} This delay was due to the fact that most specialist doctors in Nigeria were unwilling to serve in rural areas which lack basic infrastructure like water supply, electricity, a good road network, communication and good schools for their children. The situation is compounded if one of the spouses is not a health worker or a teacher, with job opportunities in the rural areas.

The author and his radiographer wife have been resident in Eruwa, the headquarters of Ibarapa district since 1983, initially as employees of the state government at the District Hospital. In 1986 they set up their practice for greater job satisfaction.

SERVICE

In the period 1983 to 2000, the operations performed included 4610 external abdominal wall hernia repairs, 903 laparotomies for sepsis, intestinal obstruction and gynaecological diseases, 534 caesarean sections, 278 prostatectomies, 155 chest tube insertions for empyema and traumatic haemothorax, 95 vagotomy and drainage procedures, 90 sequestrectomies, 88 thyroidectomies, 19 splenectomies and 11 nephrectomies.

These were possible due to the adoption of appropriate technology in the fields of:

1. Water supply-where rain water is harvested for six months of the year and stored for use in the dry season with supplementation from deep wells.
2. Energy supply-with the use of a charcoal furnace for boiling water and to power the water distiller and autoclave.
3. Lighting-the buildings are constructed with large windows; natural lighting is adequate to perform surgery in the daytime and they provide good ventilation.
4. Local fabrication of hospital equipment like the water distiller,⁴ the operating table,⁵ the autoclave, the pedal suction pump and the manual haematocrit centrifuge adapted from the rear wheel of a bicycle⁶ and
5. In-house production of intravenous normal saline,⁷ 25% dextrose and acid-citrate-dextrose solution for donor blood collection.

FINANCE

Finance is always the bone of contention in any practice, particularly medical practice in the rural area where the populace is relatively poor. For the practice to be successful, the services provided must not only be accessible and acceptable but also affordable. The adoption of appropriate, low-cost but effective technology has significantly reduced our capital investment.

In our Clinic, there is no employer or employee. We owe allegiance to our patients who receive the best we can offer and in return they sustain us within their resources. Ours is a cooperative of professionals and non-professionals offering service in the health sector and in so doing we earn our means of livelihood.

Everybody is placed on a salary agreed by all. These salaries are 20% to 50% above comparative levels in the public service. Every month a meeting of all workers is convened during which all financial returns of the month are tendered and decisions taken on payment of salaries and what to do with profit or loss.

In this way, a sense of belonging is generated in all the workers and there can be no labour unrest, as the financial standing of the practice is known to all. In a private institution it will hopefully form a solid foundation for continuity when the time comes for the pioneers to eventually take their leave.

TEACHING AND TRAINING

In the last 18 years, undergraduate and residency training has been more comprehensive and more fulfilling. Medical students and residents of various grades in Surgery, General Practice, Obstetrics and Gynaecology of the College of Medicine, Ibadan and its teaching hospital are regularly posted to our clinic for teaching and training in rural surgery.

The General Practice programme of the National Postgraduate Medical College of Nigeria adequately trains medical officers for rural surgery. That they are not moving out to the rural areas is due to factors highlighted earlier.

RESEARCH

The Alma Ata report⁸ on primary health care emphasized research and evaluation by those providing the service, those using them and those responsible for managerial and technical control at various levels of the health system. While the unavailability of modern technology has limited the scope of research, it is still possible to conduct appropriate, "low-tech," and relevant research that is subject to an excellent study design, proper controls, and scientifically valid interpretations.⁹

Modifications of standard surgical techniques have been devised to suit the patients presenting very late in the hospital. For example, gastric drainage feeding in gastrojejunostomy for gastric outlet obstruction of chronic duodenal ulcer¹⁰ and the use of Malament stitch,¹¹ a removable purse-string suture at the bladder neck, which has made the performance of prostatectomy possible at the district hospital level with an auto-transfusion rate of only 2%. ¹²

Other important research findings are

1. Incidence of ruptured ectopic pregnancy is low in a rural community and the incidence of twin pregnancies is high because the incidence of pelvic inflammatory disease, a major predisposing factor, is low;¹³
2. Outpatient groin herniorrhaphy (including simultaneous bilateral repair) under spinal anaesthesia is safe in a rural community.¹⁴

CONCLUSION

The overall effects of providing this comprehensive health service in a rural area are, (a) bringing surgical care to the doorsteps of the populace, (b) enhancement of social stability, (c) reduction in medical bills and risks involved in travelling to tertiary centres for care and (d) creation of job opportunities for members of the health team and the supporting professions.

Above all, it brings immense satisfaction to the health providers working amongst the poor majority. The challenge we face is how this innovative spirit and the sense of community commitment will pass on to younger generations.¹⁵

REFERENCES

1. Oyediran AB, Brieger WR. Twenty five years of The Ibarapa Community Health Programme. 1989 African Press Limited.
2. Awojobi OA. Surgery in Nigerian rural health care delivery-the Ibarapa experience. Nig Med Pract 1987; 13: 49-51.
3. Awojobi OA. Principles of rural surgical practice. Dokita 1998; 25:1610-2.
4. Awojobi OA. The hospital still. Trop Doct 1993; 23: 173-4.
5. Awojobi OA. Appropriate technology for operating tables. Afr Health 1994; 16:17-9.
6. Awojobi OA. The manual haematocrit centrifuge. Trop Doct (In press).
7. Awojobi OA, Fayanjuola AA, Awe TA, et al. Letter: Intravenous normal saline preparation. A district hospital experience. Nig Med Pract 1985; 10: 119.
8. Primary Health Care. Report of the International Conference on Primary Health Care, Alma Ata, USSR, 6-12 September, 1978.
9. Ajayi OO, Adebamowo CA. Surgery in Nigeria. Arch Surg 1999; 134: 206-211.
10. Awojobi OA. Gastric drainage feeding in gastrojejunostomy. Br J Surg 1994; 81: 42.
11. Malament M. Maximal haemostasis in suprapubic prostatectomy. Surg Gynec Obstet 1965; 120:1307- 1312.
12. Awojobi OA. Prostatectomy in a district hospital. Preliminary report. Nig Med Pract 1986; 11: 101-102.
13. Awojobi OA, Ogunsina SA, Adekola FA. Ectopic pregnancy in a rural population with a high twinning rate. Trop Doctor 2002; 32: 37-8.
14. Awojobi OA, Sagua CA, Ladipo JK. Outpatient management of external hernia. A district hospital experience. W Afr J Med 1987; 6: 201-204.
15. Ajayi OO. Personal communication. 2001.

Copyright 2003 - Indian Journal of Surgery. Also available online at http://www.indianjsurg.com