Editor: One paediatric intensivist’s return home to Nigeria highlights the efforts of organizations working to provide cardiac surgery care for children born with congenital heart defects, and the need for Nigeria to improve its paediatric cardiac surgery capacity.
By Dr. Bunmi Ode
Just under one percent of all children in every population around the world are born with congenital heart defects. Of these, 70% will be correctable by a single, straightforward cardiac surgery. According to UNICEF estimates, of about 7 million children born annually in Nigeria, an estimated 56,000 are added yearly to the existing pool of children living with congenital heart defects. Those children whose heart defects are correctly diagnosed are currently referred abroad for surgical correction of their defects, because paediatric cardiac surgery is not an established field in Nigeria. In fact, cardiac surgery of any kind is not an established field in Nigeria.
I am a paediatric intensivist. I take care of seriously ill children who need high-level care and monitoring in intensive care units (ICUs). I grew up in Lagos and completed medical school and housemanship at the University of Lagos and Lagos University Teaching Hospital (LUTH). I moved to the USA where I completed a paediatric residency, a fellowship in paediatric critical care medicine, and worked as an attending/consultant paediatric intensivist for a few years. In 2014, I made the decision to 2014 to explore career opportunities back home in Nigeria. The WHO estimates that Nigerians spend about $1.5 billion on medical “tourism” annually, and the most frequent indicator is for cardiac-related illnesses. Children with congenital heart defects whose families are unable to raise the funds required to pay for treatment abroad either die in early childhood or struggle with ill-health, with limited ability to function optimally in society, as their families spend large resources on healthcare needs.
My initial plan on returning was to get a feel for the Nigerian healthcare space so that I could decide how to function within it and what my contribution would be. I began to network with colleagues, and by serendipity, I stumbled on somewhat connected groups in different Nigerian cities performing open-heart surgeries for children born with heart defects. Since then, as an independent consultant, I’ve taken care of 24 post-operative cardiac surgery paediatric patients at four hospital ICUs in three different Nigerian cities, which makes up the vast majority of children who have had heart surgery in Nigeria in 2015. I have also helped set up pediatric ICU spaces and trained medical and nursing personnel in the care of these children. Although this is only a small proportion of the children in need of this care in Nigeria, it is an incredible feeling to be able to contribute to restoring a chance at life for them. Courageous efforts are being made in the field of paediatric cardiac surgery in Nigeria by some amazing groups of people, a few of whom I want to mention.
Hospitals for Humanity is an international non-profit organization partnering with hospitals in Nigeria to develop facilities for cardiac surgery, procure equipment, train local personnel, and recruit diaspora/international staff with appropriate skills. They also working to establish a referral and follow-up network for patients with heart defects, and establish a supply chain for the necessary medications and consumables. In 2015, HFH plans to facilitate 200 paediatric heart surgeries in Nigeria. So far, they have completed 25, mostly at Garki Hospital, Abuja. A recent series of seven surgeries were also done at the National Hospital in Abuja. With a record of good outcomes, this mission faces challenges of lack of sufficient funding and patient sponsorship. Though mission-based, the group is working to achieve monthly surgeries, incorporating system-development, skill-transfer and staff-training into the core of its practice.
Tristate Cardiovascular Associates is a private, for-profit group of mostly Nigerian cardiovascular specialists with extensive international training and experience. The group aims to cover the Tri-state area of Lagos-Ogun-Oyo. Most of their work is done at the University College Hospital (UCH) Ibadan Cardiovascular Center as a Public-Private Partnership. Tristate also works in partnership with Babcock University Teaching Hospital. They are working towards the launch of a private cardiac center in Ilishan, Ogun State as a result of frequent and extended staff strikes at UCH, which crippled operations for most of 2014 and 2015.
University of Nigeria Teaching Hospital, Enugu was the first center to carry out open-heart surgery in Nigeria. It first reported open-heart surgeries in 1974. They completed 102 cases over a 26-year span. The cardiac center was closed for ten years between 1993 and 2003. They now carry out missions-based cardiac surgeries staffed by international groups. Kwara and Osun states have carried out single/intermittent missions staffed by international Indian groups.
The Cardiac and Renal Center, Lagos State is a state-of-the-art facility commissioned early this year, and run as a public-private partnership with Renescor Healthcare group. Its challenges include crippling facility overhead costs and difficulty recruiting appropriately trained staff to provide services.
We can do more
In Nigeria, we are not doing nearly as many cardiac surgeries as we need to do for us to meet the needs of Nigerian children born with heart defects. We are not even close. We cannot train healthcare staff without performing these surgeries locally. Right now, Nigerian nurses and surgeons interested in Cardio-Thoracic surgery often go to train at Ghana’s National Cardio-Thoracic Center in Accra. In 2009, this center reported about 464 surgeries per year with notable expansion since then. Ghana also has a second cardiac center in Kumasi. Nigerian patients often get referred to Ghana as well as India for their surgeries.
Cardiac centers require developing vast amounts of skills, equipment and facilities; these will enhance our health system, and extend to providing services for other seriously ill, non-cardiac patients. Heart surgeries require a multidisciplinary team of surgeons, anesthetists, perfusionists, nurses, intensivists, medical officers, laboratory technicians etc. It requires optimizing blood transfusion services, teaching cardiopulmonary resuscitation, advanced respiratory support, invasive monitoring and cardiac support. These are services which our system generally lacks but needs. Developing these services will strengthen our health system and may also stem some of our healthcare brain drain.
We need to make establishing centers for the treatment of cardiovascular diseases in Nigeria a priority. These centers will help us treat and save the lives of our children with heart disease. They will also help us train local personnel to provide services. Staffing these centers may require engaging Nigerian diaspora and foreign nationals with the relevant skills initially, until we facilitate local training and skills-transfer for local personnel. Staffing models for these centers may include full-time or rotational/ part-time service. For these centers to work, there needs to be a steady stream of funded surgeries. Paying for these surgeries will require improved NHIS coverage and ease of enrollment for patients with heart disease. Government and donor sponsorship for people requiring heart surgeries should be reoriented to support local treatment.
With support, these services can be provided in Nigeria at a cost about ten times less than Nigerians currently pay abroad, without factoring in associated travel and accommodation costs. We can contain the loss of resources and productivity that heart defects currently cost our economy.
But ultimately, and perhaps most importantly, if Nigeria tackles this particular health care need, we can save the lives of hundreds of thousands of Nigerian children. We can give them an opportunity to grow up into healthy, functioning adults who will one day give back to a society that took the time to care for their hearts.
“The system we build is the system we‘ll get.”
-unknown pediatric intensivist