INTERVIEW: ‘How To Stop Doctors From Moving Abroad’

Olufemi Adelowo, MD

Prof. Olufemi Adelowo is the first Rheumatologist in Nigeria and West Africa. The pioneer trainer of rheumatology drafted the first training curriculum for National and West Africa Post Graduate Colleges of Physicians. The first African to receive the prestigious Master of American College of Rheumatology (MACR) award spoke with Online Editor Sunday Oguntola on his life, practice and the medical field.

How did you find medicine or how did medicine find you?

I think I found medicine. It started as one of these childish dreams I had. Whenever we played, I would always say ‘I am a doctor’ and put a stethoscope in my ears. It has always been what I wanted to do.

It was further re-enforced when I was growing up. I had some repeated medical challenges like sore throat. I grew up in Ogbomosho. There was this doctor, Dr. Adeniyi, who passed on some three months ago. He was the one always treating me and I admired him and the awe around him. He was the only Nigerian doctor amongst the white doctors in Baptist Hospital, Ogbomosho.

This was around the 60s. He later became a Professor of Pediatrics. That was my first encounter with a doctor, and it re-enforced my dream that I had to read medicine.

Of course you have to programme yourself in terms of the subject that you do. For the top universities like the University of Lagos and University of Ibadan, you had to pass Physics, Chemistry and Biology with top grades at a go. That was what I did. I got admitted at the University of Ibadan in 1968 and finished in 1973.

Was it an easy ride for you?

No. Reading medicine then was quite tough. We were having lectures round the clock. In the University of Ibadan, our halls of residence were far away from the lecture halls and barely had one hour break to have lunch. Luckily, we were being served; I was on western region scholarship. We would eat and rush back to lectures.

Also you had to learn about the structure of the human being; you had to learn about the way the body works. Initially, it was quite frightening because I grew up in the era of D.O Fagunwa and his Igbo Eledumare with all the ghosts and stuff. There you were in the dissection room with dead bodies.

Also, we were not having holidays at all, not like now. It was five years of intensive studies. The only time we had holidays was, for instance, if you finished a posting and you were crossing over to another; you had a one or two-week break. You had to make sure you go to the wards because most of the education in medicine is on the patients and you cannot be a good doctor if all you read is books.

However, we knew the prestige of being a doctor, so we were ready to pay the price. The joyous thing was that if you finished your exams today and you passed, tomorrow you became a doctor.

And then you specialized in Rheumatology – the first Nigerian and first West African to qualify in that field. How did that come to be?

It was a combination of factors. I had a beloved grand-mother (maternal) who had Arthritis then. For me, it was like a life mission to see what I could do to help her.

Secondly, somebody came from the United Kingdom to give a lecture on Rheumatology and I liked what he said. Eventually, I ended up training in his hospital in the UK.

Then I actually wanted to do something different from everybody. You can call it ‘arrogance’ if you like. Well, I went to the UK. I was already employed in the hospital in Ibadan. I did my residence in Ibadan.

I had already passed Part 1 and was a senior registrar, which is quarter-to being a consultant; but you still had to do some work, you still had to pass some exams.

From the time I started my residence programme in 1975, when I came back from youth service but I did not finish till 1982, because along the line, I had some references and I had to re-sit the exams.

Despite your brilliance? What happened?
Medical exams is not about how brilliant you are, it just happens that you do something wrong in the exams and the examiner thinks that you cannot function as a specialist with that mistake that you made.

So you went to the UK?

I went to the UK in-between, because before departure, which means that you are now a general physician, you now sub-specialise. Luckily enough, the federal government had a programme which you take during the youth service. You are assigned to a hospital where you spend between one and two years, depending on your specialty. You were paid estacode and you get your salaries too, just as it is done abroad. Things were good then. After that, I came back to sit for my final exams and that is the exams of the National Post-Graduate Exams, the highest exams in Nigeria. I became a fellow of the Post-Graduate Medical College in Nigeria in 1982. And then I had to go and look for a job because there was no rheumatology unit in UCH and they were not ready to start one. So I had to go to UNILORIN to start the job.

Why is so little known about the field?

You know there is quite a lot of ignorance about what rheumatology is all about. Let me give a definition that is universal. It is that sub-specialty of internal medicine that deals with the diagnosis and management of the non-traumatic muscular-skeletal system.

You recognise that our body is muscular-skeletal, the skeletons, muscles and all the joints. So, it deals with the disease of the muscular-skeletal system as well as what you call the systemic auto-immune disease. That aspect of the systemic auto-immune disease is the one that is poorly recognised everywhere because rheumatologists are few even abroad. And wherever they are, we still have records of doctors who may not have recognised what they are treating.

Systemic auto-immune disease is a condition of a strange feeling of the body fighting the cell. The body is not supposed to fight the cell because our blood is made up of water. But if one were to look down the microscope, you will see that the blood is made up of three cells: the red-blood cell, which carries food, and is the transport system of the body. Then we have the platelets, we have the white blood cells. They are the soldiers of the body, fighting our enemies, which are germs.

Anytime we breathe, we breathe millions of germs; anytime we eat food, millions of germs. When we drink water, millions of germs and they even exist in our skins. For reasons we still do not know, some of these white blood cells decide to gang-up and do a coup like soldiers. That coup can happen anywhere from the head to the toe.

When they do the coup, the loyal soldiers are not just sitting down relaxed; they fight back. This results in some rofo-rofo fights, which lead to some destruction, causing what we know as auto-immune disease.

The auto-immune disease is the major specialty a rheumatologist deals with but they also deal with non-muscular disease like arthritis, rheumatism. Not many people realise that arthritis is not just one disease. Arthritis is actually a manifestation of more than hundreds of disease. So saying you have arthritis, for a medical doctor, means absolutely nothing. It is like saying that you have headache and a doctor writes down the diagnosis for the headache. But that is not all.

How do I know that I need to see a rheumatologist?

That is a good question. One sign is if you are having persistent joint pain in any part of the body that is not responding to any treatment. That is one.

Two, if you are having many joints involved at the same time. Three, if the multiple joints arthritis you are having is associated with constitutional disturbances, loss of weight, loss of appetite, fever. Then if the arthritis is associated with deformity of joints, then you must go and see a rheumatologist.

Also, if the pain is so much that it’s almost making you home-bound, then you must see a rheumatologist, who would now institute appropriate investigations. There is no one investigation; it depends on the condition of the pain.

All the rheumatologists in this country must have passed through you. What joy do you have seeing them practice today?

If you think that you have a good thing to offer, being able to reproduce yourself is one of the satisfactions anybody can have in life. And I started with just one person when I was in Sagamu, and I was for several years in Sagamu.

Then I moved to Lagos – the College of Medicine in LASUTH. And Lagos, being what it is, it was easy to get people from all over the country in such a way that I had trainees everywhere and they are consultants in places like Sokoto, Maiduguri, Zaria, Jos, Ilorin. I have about 47 specialists.

That means that whatever message I had is being re-produced over there. It was not possible for only me to manage several patients everywhere and so we were losing them because the logistics of asking them to come to Lagos was not possible.

And because of the trainings we had, a rheumatologist can possibly live two houses away from you now, something that was only based in Lagos before. Rheumatologists are now everywhere. That’s my joy.

Do you think 48 specialists, including you, are enough for the whole country?

It is not enough, we are still growing. Presently, I have six people that are training with me. So, the number is growing. And every month, I receive calls from people, saying they want to do rheumatology. They come in and spend 18 months training with us, going through intensive trainings, because every day, they have a programme. No breathing space.

What do you consider to be the biggest skills a rheumatologist needs to be a success?

A rheumatologist is like a detective. You need to take proper history. Rheumatologist worldwide spends longer time with their patients in terms of trying to extract what the problem is. Whereas, other specialists may spend 10-15 minutes with a patient, we may spend 30 minutes; sometimes one hour to determine what the problem is. So, a rheumatologist needs patience.

You also need listening ears because every statement a patient makes, may just be the clincher. Above all, you need to empathise with the patients. We are talking about a painful situation and many of them are on this situation for years. You don’t just dismiss it and tell them to bear the pain. No rheumatologist will tell anybody to bear any pain. Pain is not a pleasant thing. You should empathise with them.

A lot of Nigerian doctors, and I am sure you are aware of this, are very eager to leave this country to go and practice overseas. What is the problem?

It is a major problem. Just this morning, I was discussing with a colleague, a doctor and I asked after his son, and he said he has travelled. And I said to him that five years’ time, we will not have enough specialists to treat our patients. He said ‘I know so’ because the older ones are retiring.

What is the problem? If a doctor gets a good hospital and atmosphere to work in, he will stay, no matter the salary. I am not aware of a good hospital where they have a good set up and the doctors walk away. That is the problem. We don’t have good infrastructure in this country. You are trained to manage patients. You are trained to investigate, make diagnosis and treat. You get frustrated when week in, week out, you cannot investigate the patients, or when the patients you are investigating cannot afford your treatment and eventually die. This gets to doctors. When you say doctors have a thick skin, are you saying that a doctor should get emotional every day facing this situation? It is not possible.

Two, we need good pay for doctors. Many people don’t recognise that doctors work 24 hours. You see them during the day but they are on calls. When they are on calls, it means a patient can come in anytime. Many doctors are overworked. If you get calls every day, you are not sleeping. Let us find out who can function maximally without sleeping for three days at a stretch.

The third has to do with post graduate training. There is now a more increasing awareness that for you to be good as a doctor, you must specialize. But we have few training institutions. If we expand the hospitals and get more people trained, they will stay.

What do I suggest? First of all, the government has to invest in its public hospitals.

Two, the government has to facilitate loans for private hospitals to expand, as it is done in India. People are rushing to India, but they did not just fall out of somewhere, the government supported them. Just as we have agric loans, the government has to come in and give loans to them. Of course, there will be people to monitor how the loans are spent, and make them payable over several years.

If that is done, many of these hospitals will take the loan, build up their hospitals and take in more patients that rush down to government hospitals. Most of the trainings in the United States are in the private hospitals. The biggest hospital in the world is private, not government. The government has no business with it. The government should invest in them and I don’t think that is difficult. One of the articles I wrote for The Guardian as a columnist was in respect of our parliamentarians collecting obscene allowances. I said if they fall sick, they might not even get to the airport. So why not improve our facilities instead?

Why didn’t you leave like the younger generation of doctors?

I left and worked for sometimes in Oman. And my very first leave, I came back. I had this very large patients waiting for me. They kept in touch with me by e-mail, asking me when I was coming back. And when I came back, every single day, I was busy. I then asked myself what the value of my life is if I have some people outside and I was not taking care of my own people. I said no, and came back to Nigeria.

How come the younger doctors don’t have this perspective?

For me, maybe being a pioneer means I could not just get out. But the younger ones are frustrated in getting into post graduate specialisation and they can’t see a way out. And then there is this pull in the UK and the Middle East. Many of them who were in the Middle East, when they come back to their country, they are like “professional orphans”, because they could not fit in anywhere. Many of them just lost out.

There is an increasing pull for African doctors. There is a shortfall of general practitioners in England and Nigerians want to fill the slot. And you know Nigerians, once they get out of the country, they do well. But for us, it is a big loss because they were trained here. The government spent money to train them, and that is always the grouse government comes up with. They train you, and then you go overseas?

The government should make provisions for them to stay back. Imagine some people talking about going outside the country to recruit doctors, just to spite the local doctors. They are not going to take the salary you give to your people here. If you give your local doctors half of what you give the expatriates, they will stay.

The argument of government is that they are going to bring in Nigerian doctors to come. But they are coming as expatriates, right?

There are two aspects to this. One is that there are those working overseas who are coming to give assistance to doctors here. They come for two or three months, take their leave and go back, because they are just here to expand the capacity system.

The ones that some of the state governments are talking about is when they want to spite their doctors, and they go on to recruit people from India. But we don’t even know the background of these doctors. Many of them just come without going through the normal registration because the government employs them and puts them in hospitals.

You cannot do that anywhere else in the world. You cannot fail to register before starting up. But here, people are starting up hospitals in Abuja and bringing in foreigners without looking at their records. This is wrong. The other thing that we need to do because there is so much pressure in the tertiary hospitals is to improve our primary health places. If we have more primary health care centres and build houses and accommodations for doctors and nurses, healthcare will improve. That is what they do in the Middle East. Where I worked in Oman, I just moved into my prepared accommodation. It is the same thing everywhere else. Nothing stops them from having borehole for water because you cannot run the hospital without good water supply. Nothing stops the hospitals from having alternatives sources of energy. Once a doctor is comfortable, he gives his best.

A doctor should not be working in LASUTH and living in Ajah, and then getting to the office by 8am to leave at night. Sooner or later, he will look for something else to do because that is too much stress.

There are some services where you should make the person comfortable because he has to be at his correct sense to deliver all the time. It is just a matter of common sense.

At 70, what will change for you?

I think I need to rest more, exercise more and I also need to travel more. Travelling is one of my hobbies but practice has not given me the opportunity. So I think I need to travel more and I should rest and take care of my body.

One of the major challenges I have, because of the nature of my job, is not resting. Even my trainees ask me, “Are you resting?’ So I know that I have to rest.

I also need to read a little more, especially biographies. I like biographies to see how people got to where they are and what they went through. And I also need to write. I am actually in the process of writing now.

What are you writing on?

I am just writing about rheumatology. I also need to write books where I need to explain things to patients. Those are my two concerns.

People also have the impression that you are hiding, a man like you shouldn’t hide.

Apart from going about the place to make noise, I also had a foray into politics. In 1987, there was this constitution review committee in General Babangida’s government. They chose two people from each state, and I was chosen from my state, Oyo State. We were to draft the constitution, and I was one of the 46 people that drafted the Nigerian constitution of 1987. We were in Abuja up till 1989. The constitution review committee wrote the constitution and submitted to the assembly for approval. I was involved in the two and I did have people suggesting politics to me. But to be honest with you, it is not just for me. I don’t belong to the class of people who say that you have to be in politics to be prominent.

I am not interested in being a politician where you get into a place, and everybody is falling down and all that stuff, and the next time you are out, people look at you with some disdain. I don’t want to be that.

I am comfortable with what I am doing. If everyone does what he is doing, without venturing anywhere else, Nigeria will be better for it.

For me, I am more concerned with what my children think of me. I want them to see me as a serious-minded person. My children’s opinion of me is very important and they are positive about me.