‘Dearth of equipment, corruption responsible for Nigerian doctors’ migration overseas’

A United States U.S.-based Nigerian doctor and inventor, Dr. Steve Teni Ayanruoh, in this interview with SAMSON EZEA, speaks on the persistent crisis in Nigerian health sector, supremacy battle among health practitioners, reasons for Nigerian doctors’ mass migration overseas, among sundry other issues

Having practiced in Nigeria before leaving for the U.S., what do you think is responsible for the mass exodus of Nigerian medical doctors overseas?
I want to look at this from the following angles- postgraduate openings, salary, quota system, corruption and job satisfaction. I will start with the availability of postgraduate positions. In my opinion, this is the most important reason doctors are leaving the country en masse. Among my contemporaries at the College of Medicine, University of Ibadan (UI), only about two to five per cent of us must have had positions to pursue a specialty residency. What happens to the others? This is not only a UI problem. It is also other Nigerian universities problem. Most people who study medicine want to specialise and there are not enough positions to accommodate all.

This lack of positions has made some of the other factors, like poor salary and quota system rear their ugly heads. In order to justify not being admitted into a programme, some people have been told that they wanted fair representation. The most connected ones among us get letters from their sponsors in the corridors of power.

The doctor’s salary in Nigeria, as at the time I left the country about 30 years ago was sickening. Doctors were making my monthly salary in an hour in the U.S. I don’t know the salary structure now. Some of my colleagues that have relatives in US encouraged them to go search for greener pastures. Job satisfaction to me is huge. By job satisfaction, I mean one having everything he or she needs to take care of patients. I remember during my housemanship in Warri, Delta State, we usually wrote a list of things needed for patients to buy for us to be able to help them.

How do you think these problems could be solved?
Needless to say corruption is a huge challenge. In a country like Rwanda, all you need to do to get anything you want is to provide what they are asking for. When you get into some offices in Nigeria the clerks will tell you ‘Daddy or Mummy your boys are hungry’. If you don’t give them anything your file will never get to their boss for attention. You pay to get anything done. The other action that needs to be taken care of is to remove quota system from the lexicon because it has done more harm than good to the nation. How can an intelligent person be punished, because of where he or she comes from? To me, the most important reason for the exodus is the lack of available residency positions. I believe that this can be tackled if the government focuses on solving this problem.

In the U.S., residency in specialties is done in university teaching hospitals, city (local government) hospitals, as well as in private hospitals, as opposed to only teaching hospitals in Nigeria. I think the Nigerian government can adopt this method too, but certain policies need to be put in place first. The Federal Government can assemble a board of certified experts in the individual specialties to write policies for their specialties. These should be adopted by all the state and local governments.

These experts should also advise on equipment requirements for their specialties. Finally, the Federal Government should also setup a certifying body that will periodically recertify these hospitals. This will ensure maintenance and adherence to standards. I think as more consultants who can supervise these residents are produced more people can go into residency of their chosen specialties.

From your experience, is it better to practise in overseas than practising in Nigeria?
Yes, it is a lot better to practice medicine in the U.S. than in Nigeria. In my opinion, there is no basis for comparison. If both locations are compared electricity, roads, infrastructure, equipment, medicine, other accessories like bandages, plaster and splints as criteria, people will appreciate the differences. There are established standards and policies in all the health facilities in the United States of America. I will try to highlight some of the differences using the above criteria.

There is constant electricity supply. You need electricity to power the computers, examination equipment, ventilators and surgical operations, among others. Power outage in developed countries is a big deal. As we speak, there are so many people being treated in Nigerian hospitals in darkness. Some might be having emergency surgeries and the light just goes off, resulting to the hospital executives scrambling to turn on the generator. Only God knows how many people have lost their lives this way.

In the U.S., oxygen, medical air and Medvac have outlets in the walls. Therefore, you have access to them 24 hours, seven days a week. In Nigeria, oxygen is stored in cylinders. What this means is that the lives of people who would need oxygen, depends on the action of one person or company. The opposite is the case in the U.S. I lost a relative from an asthmatic attack in Otukpo, Benue State, because they did not have access to a nebuliser or oxygen when he had an acute exacerbation.

It is very easy to have access to medical care in the U.S. There are good network of roads and ambulance services. In disasters where it is difficult to evacuate with vehicles or other mode of transportation, helicopters are used to transport such patients to the hospitals. In certain situations, a patient who needs a specialised emergency care is also transported to the hospitals in helicopters. When I compare this with my national youth service days in Obuohia Ibere in Ikwuano Local Government Area of Abia State, there is no comparison. Whenever it rained at that time, driving for the last one to two miles into the village was like a car with very smooth tires driving on an oil coated glass surface. It was a death trap. It was not surprising to see drivers refusing to go there when the weather was bad.

Most doctors, if not all, will be happy to work in an environment where they have access to equipment and medicines. Many politicians promise to build hospitals for their communities. Some keep their promise by building and beautifully painting them but not adequately equipping them. I will rather prefer a hospital built with thatch and mud but well equipped to an unequipped beautiful structure.

In the U.S., technology is being put to use in every facet of life in the society. Currently, prescriptions are sent directly to the pharmacy of the patient’s choice by the doctor, thereby, eliminating poor handwriting, medication error and poor record keeping.

As at the last time I visited Nigeria, I still noticed that doctors are using paper charts (medical records). This is cumbersome. Misfiling is very common with this method. No wonder patients are issued new medical records (cards) with almost every visit to the hospitals. This does not help to keep good medical history of Nigerians. In the U.S., Electronic Medical Record (EMR) is very common. There are still some old doctors in private practice who are having difficulty in embracing the new technology. With EMR, there is no misfiling. Searching the database is very easy. Statistics of many parameters are extremely easy to derive. The EMR also keeps a comprehensive medical history of their patients.

What really made you to leave Nigeria for the U.S?
I applied for a job in the NNPC as a Medical Officer in Warri in 1989. After the interview, the Personnel Manager in Warri informed me that I was the successful candidate and my appointment letter would be coming from Lagos. I am still waiting for the letter 29 years after.
A few weeks after my interview with NNPC, a classmate of mine knocked on my door at about 8pm. I was surprised, though happy to see him in Warri since he was not from that part of the country. On further questioning, he told me he had come to resume at NNPC. I said I am waiting for my letter of appointment from Lagos. He said “so na you?” I replied “wetin be so na you?” He replied “them remove your name and put my name because I claim say I come from Kano State”. This was when I decided to leave Nigeria.

Do you have any regrets leaving the country?
No. I do not have any regrets leaving Nigeria. I consider myself blessed and I give all Glory to the Almighty God. My coming to the United States has educated me in ways of life in the civilized society and how people are governed and treated in addition to my postgraduate training. It also taught me that 24/7 electricity is the normal way of living.

I learnt that ambulances are for sick people being taken to the Emergency Department of hospitals and not to carry corpses to their final resting place as in Nigeria. I learnt that it is the responsibility of the local or state government to provide accommodation and food for the poor. They have different programmes namely Section 8, WIC (for children, pregnant and breastfeeding mothers). I learnt that it is the responsibility of citizens to pay their taxes. I also learnt that the U.S. government will do all they could to advocate for their citizens.

I will give you an example. If a Nigerian and an American are competing for a contract in Ghana, the U.S. State department, provided the American goes through the normal process, will represent their citizens at the top level to secure the contract for him. There are different classes of representation and each has a processing fees. The highest class of representation being the U.S. President advocating for their citizens with the President of Ghana. This is why, in my opinion, Americans love America. I know this because I personally experienced it.

There are so many resources in this country that actually help make me an inventor. I invented Hospital-In-A-Box, which has made it possible for the Hospital to go to the patient and not the patient going to the busy hospitals, Wet-N-Beep diaper (the diaper sensor beeps and lights up when it becomes wet) and my latest invention called Scomet, which can be used to examine the ear, retina, temperature and take pictures. This will be done in a few weeks. I am sure you see the reason I do not regret leaving Nigeria.

Have you ever made any attempt to bring back your exploits back home and got encouraged or frustrated by the government or people?
I believe that it is the right of every citizen to have access to basic comprehensive healthcare irrespective of age, colour of skin, creed, economic or educational status, race, religion, sex and social status. Nigeria is in serious need of good healthcare hence I have been making efforts to bring Hospital-In-A-Box to Nigeria since 2007.

I know that it will help improve healthcare delivery in Nigeria. That year, I gave a demo to the Nigerian Army in Abuja. During this visit, I was also able to give a demo to the then Chief Medical Officer (CMD) at the Aso Rock Clinic, the Chief Ophthalmologist and Chief Dental Officer during President Olusegun Obasanjo’s administration. They were so excited over the invention, particularly with the ECG capability of the device. The ECG machine in Hospital-In-A-Box prints on regular paper. I was made to understand that the ECG machine in the Villa was locked up for many months because they never had the special paper that the machine prints on.

I have made several representations to past and the present administrations, ministries and government parastatals, including the Niger Delta Development Commission (NDDC) with little or no way forward. Also, I gave a demo to the Minister of Health during the late President Umar Ya,Adua’s administration, who was so excited that he asked me to submit a proposal. He promised that I would be contacted. I submitted a proposal and was never contacted.

In 2013, during the luncheon organised for President Goodluck Jonathan and the Business community in the Diaspora in New York, I was lucky to get his attention. Mr. President said “Minister of Health, talk to him”. We had a meeting about two days later and I was asked to re-submit a proposal. I made several trips to Abuja and was finally referred to the National Primary Care Development Agency, where I met with the then Executive Director. He later set up a committee to look into possibilities of partnering with the agency in bringing the machine to Nigeria. The head of the committee contacted me and asked me to submit a proposal for a partnership with the agency. I submitted the proposal and I have not received any response from the agency.

I was also at Asaba, my state capital about two years ago to meet with the Health Commissioner. He promised to get in touch with me but nothing has been done since then. I have also communicated the Secretary to the State Government. He told me they don’t have money.

As you can see, I have made tremendous efforts in bringing Hospital-In- A-Box to Nigeria. This is because I believe charity should begin at home. I have not given up in trying to help improve the healthcare delivery in Nigeria. I have decided to take it directly to the citizens who really need the care. I will be ready to talk to the government and especially the Managing Director of the Bank of Industry (BoI) to see how they can setup entrepreneurs using Hospital-In-A-Box. Those with political and economic powers can afford to go overseas. But I promise every Nigerian that when our programme is fully executed, we hope to drastically reduce the rate of medical tourism. I intend to create business owners and jobs using Hospital-In-A-Box. Nigerian citizen using our App will be able to request for a healthcare provider that has been trained to use the device.

After examination, the healthcare provider will send all the data to our HIPAA compliant website from where the doctor working with the healthcare provider will review, make diagnosis and treat. Every patient will have his temperature taken. Their Retina (inside their eyes) will be examined. People don’t get their retina examined usually unless they visit eye specialist. Their lung will be examined using spirometer. The lung can either be normal, restricted or obstructed. Obstructed lungs will be treated immediately with a nebulizer. The oxygen content of their blood will be measured using a pulseoximeter In short, they will receive the best examination ever. This is my promise. I advise everyone to be on the lookout.

So, from experience, are you saying that mass exodus of Nigerian doctors to overseas is justifiable?
I can definitely say yes for myself, because I never had a godfather, hence I could not get a residency position in Nigeria and the job I was offered at NNPC, Warri was eventually taken away from me, because I was not from the North. Every person that left Nigeria might have their unique reasons, although Nigerian universities were turning out doctors with disproportionately lesser postgraduate positions. Most Nigerian doctors wants to specialise and since there are not enough positions to accommodate everyone, they have no choice but to leave Nigeria.

What do you think is actually wrong with Nigerian health sector system?
The most important ingredient missing in Nigerian health sector is leadership. A country that cannot treat its President has a serious national security issue. Nigeria is endowed with brilliant doctors that have made name overseas. The Association of Nigerian Physicians in America (ANPA) has a collection of doctors who have made names for themselves. Examples include Dr. Oluyinka Olutoye who operated on an unborn baby and Dr. Bennet Omalu who discovered Chronic Traumatic Encephalopathy (CTE). This is a disease that affects American football players. His discovery resulted to the American NFL making changes to their game rules to make it safer.

I will advise all health ministers and commissioners to go through all the hospitals in their jurisdictions and ask themselves this simple question: ‘If I am involved in a serious motor accident or I can’t breathe (bronchospasm or asthmatic attack) as a result of allergy to something I am unaware of, will this hospital be able to save my life?’ If the answer is no, then it is time to upgrade them. In the past, government built hostels and call them hospitals because they buy hospital beds and side tables. It is only by the special grace of God that people are living. A hospital, to me, is not the building because the building cannot save lives but the equipment in the building can be used to save lives.

I wish the government could designate certain hospitals as specialty hospitals if it will be too expensive to upgrade all hospitals to world-class standards. I remember the UCH from where I got my foundation. I also think that continuing education should be made mandatory to doctors to enable them to always upgrade their knowledge.

It has been observed that Nigerian doctors, pharmacists, nurses and laboratory scientists are always at loggerheads over promotions, salary disparity and others, what is obtainable in the U.S.?
I don’t know what the problem is. My understanding of this agitation is that a flight attendant who does the hard work and the pilot should be paid equally, the labourer who does the manual labour and the Civil Engineer or the Architect who through their knowledge prevent structures from collapsing, should be paid equally, the orderly and the nurse should be paid equally.

The doctor is always the head of the health team in any part of the world. They also have the most tedious curriculum and stay the longest in school to get their degree. Any of the other professionals agitating for equality with doctors is not who or what they claim to be because if they went to the school they claim to have attended, they will know there is no basis for this agitation.

Doctors are the highest paid in the health sector. Even among the doctors there is salary differences. A Neurosurgeon receives more than a gynaecologist, which in turn gets more pay than Primary Care physician. I truly do not understand what the issue is. From my discussion with some Nigerians, I discovered that some of them associate experience with age. If an older nurse will not want a younger Doctor to be her boss, then I don’t know what to say. There should be no reason for argument. Why don’t the older nurses operate on patients instead of the young doctors; because they are not certified to do that? This is one of the reasons the country is regressing because people who are unqualified are given positions they are unqualified for.

In the U.S., we have nurses who attended nursing schools. Some go a step further to do a bachelor’s degree. The different classes of nurses perform about the same functions. There is a salary difference. Some of them go back to the university to study to become nurse practitioners. A Nurse Practitioners (NP), as they are fondly called, can see patients and write prescriptions. They are paid higher than the other nurses but less than doctors. There is another class of practitioners called Physicians Assistants (Pas). They see patients and write prescriptions. The difference between NPs and PAs is that a PA has to be supervised by a Doctor. PAs receive slightly less than NPs. I give clinical training to NPs and PAs from Lehman College and Pace University in my private practice and at Lincoln Hospital in the Bronx.