‘You.. you’re not Romanian right?’ my cab driver bristles over his greying moustache as we pull away from the train station in my hometown Brăila. I smile as I continue, in fluent unaccented Romanian, what is one of my favourite but also most loathed conversations: where I’m from. His Dacia Logan is barely clean on the inside, aged but sturdy. Having become ubiquitous in Romania over the past decade, the Logan has unassumingly taken its place as the flag pole Romania has buried in the new capitalist world it’s found itself in since the fall of communism in 1989. Relevant is the fact that Dacia, a historically nationalised Romanian enterprise, was bought by French Renault in 1999 and today, Dacia-spurning plants are sprouting up in Morocco to fulfil demand in Europe and West Africa: globalised capitalism at its best.

I digress.

I instantaneously forgive my cab driver for attempting to strip me of my birth in one of Bucharest’s most renowned hospitals, my very Romanian middle name and all my summer holidays spent doing very Romanian things. Swimming at the local pool with my friends in the 36+ degree heat, eating cotton candy while playing at the local “Orășelul Copiilor”, being overfed sarmale (meat & rice — stuffed vine leaves) by my grandmother amongst other things. This autonomic rejection of what doesn’t feel familiar or fit into a nice box, sometimes branded ‘othering’, seems to be something we’re sadly beginning to excel at again nowadays.

“The othering process is the human tendency to believe that the group (race, religion, ethnicity, culture, gender, country, sexual orientation, species etc) that one is a part of is inherently the ‘right’ way to be human. As a consequence of this, people who ‘other’ – either consciously, or subconsciously, believe that anyone who is not a part of their group is a threat, an enemy or a liability that must be converted to conform immediately to the norms and standards of their group, subjugated permanently, or eradicated completely.”

— @TheAdvancedApes

As a ‘swirly’ product of globalisation, it is difficult for me to ignore racial, socioeconomic and identity issues. My Dad says I’m too sensitive and that I should just get on with it. For him as a medical student in 1970's Romania, if he would have stopped to correct every single misplaced opinion (i.e. do your people live on trees? do you have a tail?), he’d have had little time left for studying. But as I reflect on buying Swiss Chocolates from Chinese shop attendants in Munich Airport on my way to Romania, or partying with caucasian American actors at a shebeen in a South African township, or eating Colombian bananas during my lunch breaks in rainy northern England — it’s difficult for me not to affirm how inter-mixed our world is.

Over time, my identity has solidified and I’ve come to embrace the respective countries that contribute to my cultural heritage, I feel less pressure to fit in and have come to celebrate the differences and similarities I share with those I encounter.

When I returned to Nigeria in 2003 for my first time as a teenager, my parents forbade me from walking on the street alone outside of the compound where we lived. It was unsafe, I could be kidnapped, I would attract attention as an ‘oyinbo’. I disobeyed; of course. Asides from constantly wanting to peel back the veil & discover what perilous adventure this world forbidden to me held, till today, the energy that pulses from Nigerian streets magnetises me to them.

The two chiselled guys taking each other to blows while traffic builds up behind the cars they’ve left parked in the middle of the roundabout mid-collision, the young girl aggressively selling peppers to anyone who will give her attention, the inexorable sun, the harmattan dust colouring my fingernails, the palpable potential of 180 million people all vying to succeed. It’s intoxicating.

These days I am less coy. I think I’ve accepted that I’ll never be seen as ‘Nigerian’ & embrace my role as the tall oyinbo — winking at the giggling group of children waving at me as I walk by; perfecting the art of eeling my way out of strangers in airports/petrol stations/newspaper stands asking me, “oga, wetin you bring for me from the USA?” Have I been kidnapped yet? No. Will I continue to explore? Probably.

We need to get over our habit of categorising people. “Where did you study?” “Where are you really from” “What work do your parents do?” “What religion are you?” As our world slowly becomes more populated with placeless nomads that have multiple cultural, geographical and ideological identities, we are going to have to get used to individuals not fitting into neat boxes we can place in a divider on our filing cabinet.

I’ve felt most comfortable in environments where I didn’t have to start explaining why I was a particular colour or spoke a particular way but engaged on shared interests, hobbies, plans or ideas. I don’t have a “mixed-race agenda” (some of my friends will disagree) and I’m not advocating that we eliminate individuality, culture or heritage. I am also aware of my privilege and how it has coloured my vision of the world: namely having engaged in trans-continental travel from a young age, interacted with individuals from multiple cultures as well as having a tertiary education.

So I will wield my privilege to the best of my ability as I navigate through our delicately interwoven world. I will strive to do this even as the UK tries to make its immigration laws more stringent and ISIS tries to make the Middle East uninhabitable for anyone that doesn’t share their extreme ideology, while Uncle Donald tries to find funds to build his wall — because I don’t really have a choice, and you might not either.

Below is a short true story about a woman in South West Nigeria.

My mum, together with my Dad, work as OB/GYNs in a small, NGO-run hospital in Osun State. She told me the following story about one of her patients.

She was a 31 year old English school teacher who was brought to the hospital last Friday morning after having been in labour for what was *apparently* three days (it was probably more like 4 or 5). She was 40 weeks pregnant (again, another assumption because she had no antenatal clinic attendance records) and she was due. She had one girl born by Caesarian a couple of years ago. She went to the mission house to deliver when her waters broke and had been under their “care” but began to deteriorate so they decided to bring her to the hospital.

On admission, her blood pressure is 85/50 and dropping; her heart rate 120, her temperature 39.5. Unconsious and unrousable, her airway is at least secure and she’s breathing. There are no uterine contractions and no fetal heart rate to be found (using a Pinard of course… Sonicaids are a luxury; talk less of a CTG). Her haemoglobin is 6 and her PCV is less than 0.25 (that’s all the investigations she can afford for the moment). She is fluid resuscitated, given IV antibiotics, family is consented, she’s cross-matched & taken straight to theatre. Her family friend who works at the hospital rushes to the administrator to say that she’ll pay. Her husband can’t afford the ₦75,000/$450USD bill. They pray in English before the operation begins: she was an educated lady.

On entering the peritoneum, they’re met with a rank stench. The previous cesarian scar is slightly open and oozing greenish pus. They enter the uterus though it. The 40 week old baby is so dead, its grey flesh begins to peel as they dislodge it from the festring uterus.

It is disposed of.

Cleaning out the placenta & membranes from the uterus is even more treacherous. Her uterus is an atonic mush of green decaying membranes, pus, blood and rancid fluid. She is given IV syntocinon and ergometrine. They somehow manage to suture up her uterus: maybe, just maybe, she might be valuable to her husband at the end of this surgery. Back in the abdominal cavity and her omentum is riddled with locules of pus that have adhesed her intestines and her anterior peritoneal cavity into one. They I&D them one by one. Fill her peritoneum with saline. Suction out the cloudy porridge. Repeatedly. She continues to live.

After salvaging what they can of her fertility and gastroinstestinal tract, she is closed up and continued on IV antibiotics. She comes to in recovery and struggles in and out of consciousness for the next couple of hours. The blood loss and sepsis continue to take their toll. She came too late.

She passes Saturday morning.

My mum has become so blazé about things like this, they happen so frequently. She goes on to tell me of another patient they had in over the weekend who had twins and was also in labour for an indescript time in a mission house, slowly incubating trothes of bacteria in her reproductive tract as she was repeatedly examined by the well-intentioned midwives and paraprofessionals. She survived & so did her twins.

Mission houses are a symptom of the systemic failure of healthcare in the South West. They are normally attached to a church/religious institution and just might be staffed by a trained/experienced midwife. They are places where parisioners can come to recieve heavenly healing for all the diseases of the body IN THE NAME OF JESUS! They are the place of first presentation for many pregnant women and ailing patients becuse they simply cost less than the professional services offered by government and private/NGO health facilities or are “free”.

Well at face-value anyway. You still have to bring a goat or two, some chickens, Coke and garri for you to feed everyone when your child is born (money for parties you see, we always have).

The sad thing is, that when you add all of those costs together, sometimes they come out more than if you’d have just gone to the hospital in the first place. They barely have any of the amenities and equipment of a well organised Nigerian equivalent hopsital; maybe some saline and a few shots of oxytocin, some pain relief and a “sterile” instrument or two but that’s pretty much it. The special attraction of these mission houses is that there is special anointing and healing power there (IN THE NAME OF JESUS), and more prayer than you know what do with. I have nothing against the good intention of these institutions who are genuinely seeking to fulfil a need, and fill a gap in the healthcare system, its just that the results of their work is not often as ideal as it could be. Lets not even begin to talk about the animist shrines which take things a step further in terms of playing games with one’s life.

My mum says that women will often come to her antenatal clinic at the hospital , and then go deliver at one of these mission houses. They’ll only come to the hospital when they’re on deaths door; and I can hardly blame them. Even government subsidised services at the local tertiary referral centre are eye-wateringly expensive for the local population, who on average, I’d estimate earn close to $250USD a month (and that’s being generous). An CT scan costs ₦40,000($240USD), and that’s if you know people in high places to hook you up (and if there is stable electricity to run the thing in the first place).

On two random A&E shifts I did, I witnessed the death of two patients that were simply brought too late, and all that could really be done for them was to make them comfortable as they died. One had severe HIV encephalopathy & the other we still don’t know — he barely had a pulse when he was brought into the department. & lets not begin to talk about the emergency services. Your ambulance will normally be the car of a kind passer-by driving by your RTA…

You have better chances of Santa Claus picking you up in his sleigh than enlisting the services of an ambulance.

What’s more painful than this is how women are treated like baby-making machines. Another patient was in a similar situation to the school teacher who passed, only that she was unlucky enough not to have any family friends in the hospital, and a business-man husband who was “busy” finding money to pay her hospital bill. After her life-saving caesarian (which involved a hysterectomy), when her family found out that her child did not survive, she was not visited by anyone for a good three days. Eventually her husband turned up with some money, but nothing close to what was needed. For them, she was as good as nothing without a uterus. There are patients who end up living on the hospital grounds for weeks due to unpaid hospital bills.

The system is so broken I don’t even know where to begin, and I suspect neither does the Nigerian Ministry of Health or Medical Association, which is why they strike instead. From a lack of ubiquitous structured antenatal screening programmes, to non-existent social insurance, to under-staffed hospitals, to visionless leadership, to medical schools that go on strike for years on end preventing graduates from qualifying, to entrenched interests in broken referral pathways remaining broken, to a lack of readily accessible data at a micro and macro level, to expired, fake medication, to patients simply not having enough money, it is heart-wretchingly painful to watch Nigerians die like chickens from preventable illness.

The least we can do is tell their stories. These are all real people with families hopes, dreams and aspirations. They’re not just a WHO statistic on a fancy infographic.

May they rest in peace.

Photo credits: Energy for all 2030 [Flickr] & Lady Kate [Flickr]

& for more photo’s from my 2013 Nigera trip: Flickr Photos

Originally published at oluwatobi.co.

Originally published on the 12th of December, 2013.

I’ve been meaning to write for a while, but a conversation I had today gave me the necessary fodder that ignited a spark in my engine, which propelled my ammunition… ok I’ll stop.

Ever since the 2010 election, as the new Tory-Lib Dem Coalition governments’ slight modification of Andrew Lansley’s vision for the NHS has started coming into fruition in the shape of the Health & Social Care Bill (now an implemented law), there has been a lot of talk about the privatisation of the NHS. Opponents of the changes often use anti-Tory sentiment and frequently reference the unseemingly large number of Tory MPs and Peers that have financial stakes/other interests in private healthcare companies. Clearly, a privatised NHS would be good on their pockets. Also cited are some of the negative consequences of private healthcare companies running rampant, such as costs rising due to companies inflating prices to maximise their profits for their shareholders.

Examples of low quality care are also quoted such as Serco’s failings and so are examples where services taken over by private companies have been disastrously dangerous, expensive, and have complicated care pathways for patients, not simplified them (see exhibit x y z). For more doom & gloom on the scourge of the private healthcare companies please refer yourself to the Guardians health section, where you will find some highly left-infused brazen commentary that would make you think private companies are the spawn of the devil himself.

Now don’t get me wrong, I am not here to ridicule or discourage brave and honest journalism or party politics, but I think politics form a large part of our problem in British healthcare. If I were to pick a side myself, I would probably swing left with a pinch of right-centre -ism. But my fear is that by muddying the waters with political sentiment, we may miss out on the opportunities to radically transform our health service for the better, which we urgently need to do (need I refer you to all the disaster reporting on the NHS A&E crisis, the rising costs of care, the funding shortfall, the staffing shortages, the poor quality care that led to the Mid Staffs inquiry etc).

There seems to be an endless amount of woe out there for us to drown our sorrows in & regress deep into a murky pit of negativity about our health service.

Simply put, the NHS is incredible. It provides a large number of healthcare services for every (tax & non tax-paying) member of British society. It does not discriminate against your ability to pay, your social class or your ethnic background. It prioritises who it provides healthcare for on the premise of how much you need it, not how much you can pay for it. It is a jewel in the crown of the United Kingdom. However, that does not mean we don’t need to improve it and make it sustainable as our society continues to flux. A conversation I had today gave me some insight into how the private — public debate has the potential to limit what we can achieve.

I was being taught by a microbiologist who works at a DGH I’m attached to at the moment and they were describing how the pathology service at the hospital has changed over time. 12 years ago, they were the first hospital in their area to outsource their pathology services (microbiology, haematology, clinical chemistry etc — all the back-end, dark alley of the hospital important stuff) to a private company which will remain unnamed. They described how they had tried for a while, as they struggled to maintain running the service at their hospital, to use the pathology labs of a nearby tertiary NHS hospital that had some extra capacity. Their samples were not prioritised, problems with deliveries wouldn’t be followed up and they had a pretty poor experience, leaving them with no option but to use the services of the private company exclusively.

They described how most path labs in most NHS hospitals close at 5pm and technicians will go home, leaving blood tests/blood cultures unfinished and unstarted till the next day (there are obviously emergency services). This lengthens the time taken to receive results and get on treating patients for the right condition/bug. They expressed great satisfaction with the private service, as it was all-in-all cheaper, more timely (couriers and labs ran 24/7 on an efficient shift system) and more responsive to the needs of the hospitals doctors and microbiologists. The private company adopted the use of the appropriate IT, implemented it well and made this doctors lives much easier. This has been happening for 12 years. Hmmm, so not the typical fire-breathing private company we’re accustomed to eh?

Why do I use this example? I think it is important that we start talking about what really matters in healthcare, drop the politics and focus on results. Evidence based healthcare anyone?! Yes, private healthcare companies have shareholders. But so does the NHS. Me and you, the British taxpayer. In as much as private companies’ shareholders finance their growth & expect a return on their investment, why should we as taxpayers feel any different? The NHS isn’t free. We all fund it, directly or indirectly.

I exaggerate for a reason. Let us stop focussing on private this, NHS that, vested interest this, evil companies that. I don’t think that NHS managers lie awake a night thinking about how they can make their service more equitable and how they can imbue the principles of the NHS into their every step & breath. They worry about targets that they get paid for if they meet and worse, penalised in cash if they don’t. They worry about CQC inspectors’ unannounced visits. They worry about budgets for their crucial services being cut and how they can make more money for their organisation to keep doing what it does. Please tell me, how does this differ from what a manager at a private company does? No, no… she’s busy trying to find ways to milk as much cash out of her customers as possible.

The NHS isn’t free. We all fund it, directly or indirectly.

And let’s please drop the name calling and finger pointing that runs so deep in the grain of how the NHS works. If we really want to point fingers, it was the Blair government that introduced things like the “internal NHS market” and outsourcing to AQP (Any Qualified Provider) amongst other evil free market instruments. So much for left-soaked social equity. We need to focus on creating and structuring services that work and work well for those who we are serving: patients. We need to find increasingly cheap ways of doing this & fast. We need to find better ways for public and privately funded organisations to work together and learn from each other; not constantly attempting to hack off each other’s heads.

What I’m not saying: privatise the NHS because private companies do everything better than publicly run companies and hence should run everything.

What I am saying: let’s drop the public-private, Labour-Tory bashing. Let’s talk about what matters, and let’s focus on what works, is equitable and costs the taxpayer/public shareholder the least amount possible. We’re going to need every penny.

Disclaimer. I am not claiming to be an expert on any of what I’ve written about and have probably made a myriad of assumptions and mistakes. I’m just trying to stimulate conversation. Hopefully it’s the right kind of conversation! And if I’m hanged at the stake for my opinions, so be it. My blood is on your hands.

Originally published at oluwatobi.co.

Quick thought for the medically minded.

I just wonder why medical schools (mine anyway) aren’t spending enough time teaching us (future medics) methods of helping people actually lose weight. From my experience, limited as it may be, I’ve noted that a lot of the medical profession’s approach to fatness is mockery, disdain and an air of superiority over these uneducated, fat, poor people who don’t know any better. It has been drilled into us that the first line intervention for people with Diabetes is “diet & exercise” but how do we go about supporting patients to make that actually happen?

We are taught about bariatric surgery & its drastic effects and the “wonder-drug” orlistat (Google “Orlistat side effects” to understand just how amazing it is). I just wonder how much money could be saved in unecessary surgery and drugs for the multiple consequences of overweight and obesity. It seems like our response to fatness right now is to avoid talking about it & “refer” to a dietician, then either band the fatties’ stomachs when their BMI hits 40 or make them sh* out their floaty unflushable insides.

I recently met a patient while I was doing Rheumatology who had really bad Osteoarthritis that affected her knees but was worse in her hands. I found out about an interesting theory which is that a lot of the problems with OA aren’t simply due to mechanical stress, but that there are inflammatory markers that are activated by the excess fat which can give OA patients a RA-esque polyarthropathy of the small joints (here’s some more on this if you really want to geek out). I may be years late to knowing that, but nevertheless, it highlights to me how important weight loss is for overweight and obese people.

Weightwatchers & other similar organisations are making millions, probably billions from our fatness and there are a hundred and one recommended diets & weight loss programs which have a sketchy evidence base at best. Shouldn’t we be using the potentially therapeutic relationship between doctor & patient (physio & patient/nurse specialist & patient) to improve patients attempts at losing weight & stop a lot human suffering and £$ loss?

From the medical school exams I survived this summer past, I was expected to learn and regurgitate abstract information about a myriad of obscure infections that we have vaccines to. So solving the problem is all about getting the vaccine to the right people.. and sorry but how likely am I in my 40 year career as a doctor going to see someone with mycobacterium marinum.. or babesia spp… BABESIA?! yup, that was in my exam.

The thing is, unless the medical profession starts dealing very seriously with the matters of fat, weight loss, hyperglyceridaemia, a lack of exercise, metabolic syndrome & the resultant myriad of diseases that are going to affect EVERYONE in the coming 30–40 years we are going to remain plumbers, cutting out slabs of fat and tying knots in people’s gastrointestinal tracts whilst not fulfilling our potential as healers.

There are thousands of apps out there that are growing in prominence and a hoarde of very intelligent programmers and engineers who would like to replace us and make a big buck for it. The medical profession needs to adapt or be automated. This is if we truly want to continue delivering the standards we’re called to by the Hippocratic Oath. Yes there will always be space & a need for those that are going to deal with the problems that arise as a result of the inevitable consequences of life: surgeons, A&E doctors et al. However, as as we’ve learnt with smallpox, polio, cholera, TB, HIV and a number of other things that have kept doctors busy over the past 200 years, prevention is better than cure.

I am confident in the ability of the next generation of doctors to apply themselves to the world’s most pressing problems — as opposed to thickening their CVs with irrelevant papers, published only for career progression, competing for a smaller pool of jobs in the most “prestigious” tertiary instituions & seeking to milk rich patients for all they’ve got… or maybe my confidence is misplaced… who knows.

*sips tea*

Originally published at oluwatobi.co.