by

 

Oluyombo  A  Awojobi

National Secretary, Association of Rural Surgical Practitioners of Nigeria.

Awojobi Clinic Eruwa,

P O Box 5, Eruwa, Oyo State, Nigeria.

mobile phone: +234 802 420 1501

email: oluyombo2@yahoo.co.uk

 

 

 

Nigeria could claim to have given the blueprint of primary health care delivery to the world 15 years ahead of the World Health Organization’s Alma Ata Declaration on the same subject. In 1963, the Faculty of Medicine, University of Ibadan, initiated this momentous programme, based at Igboora in rural Ibarapa District of Oyo State, South Western Nigeria. Professor (now Emeritus) T O Ogunlesi, OFR was the first director for fifteen years. Although a cardiologist, he is better known as a community physician.

 

The specific objectives of the programme are:

(a) To teach medical students and doctors, through practical work the principles and practice of community medicine.

(b) To study the problems of health care delivery in the Ibarapa Community and to develop the health services of the district into a model of what an integrated local health service should be, in collaboration with the Government of Western Nigeria, in a manner which can be applied to other rural districts in Nigeria and other developing countries.

(c) To carry out research into various aspects of health and disease in the community, and thus to build up a body of knowledge on the various factors (social, economic, epidemiological, statistical) which are involved in health promotion and disease prevention in rural communities.

 

In an attempt to provide the surgical component of the programme in the late seventies, the Department of Obstetrics and Gynaecology and the Department of Surgery of the University College Hospital, Ibadan sent registrars on monthly rotation to the District Hospital, Eruwa – the only hospital in the district at the time. This arrangement was strengthened by the appointment of the late Dr C A Pearson, a Briton, as the Chief Medical Officer of the programme by the Faculty of Medicine in 1975 and was further boosted in 1983 when Dr O A Awojobi, a general surgeon and an alumnus of University of Ibadan, took up appointment at the District Hospital, Eruwa an employee of Oyo State Government. Due to bureaucratic bottlenecks, he resigned in 1986 to set up a private practice, Awojobi Clinic Eruwa in Eruwa town.

 

Dr Pearson was a well-known missionary and clinical researcher. He had spent the previous 23 years building up the Wesley Guild Hospital, Ilesa in Osun State also in South Western Nigeria, to its present international status. He and his wife, Jean, lived and worked at the Rural Health Centre, Igboora for eight years performing some weekly elective surgery at Eruwa, 25km away. Incidentally in the early 1900’s, Igboora was earmarked for the Wesley Guild Hospital but due to the cultism of the people it was shifted to Ilesa.

 

In 1980, Dr Pearson and other notable Nigerian general practitioners founded the Faculty of General Medical Practice (Family Medicine) of the National Postgraduate Medical College of Nigeria, NPMCN, in Lagos.

 

The Association of Family Physicians of Nigeria (AFPON) was launched in 1998 to promote Family Medicine which is the medical specialty that endeavours to provide comprehensive primary and secondary care to the entire family unit from birth to old age. It aims to address the most frequent medical/surgical problems in the population and can be considered a specialty of common diseases. They are trained to treat patients in the context of the entire family.

 

The early history of the Faculty was closely linked with that of the Association of General Medical Practitioners of Nigeria as well as the Nigerian Medical and Dental Council.

 

In the early 1970s quite a number of young doctors after their housemanship and varying periods of tutelage in public or private sectors opted to go into private general medical practice on full time basis. Consequently, a lot of new clinics and hospitals sprang up to meet the increasing demand for such services in many parts of the country especially the industrial and commercial centers.

 

At that time in Nigeria, if you were not a specialist surgeon, physician or gynecologist you were simply called a general practitioner and if you had the right connections you could eventually be made a fellow of the Nigerian Medical Council in General Medical Practice by that body.  However, you were not accorded the appropriate professional status, regard and recognition by both the public and your specialist consultant colleagues.

 

A few young GPs practicing in Lagos who had decided to make a life time career in general medical practice got together and resolved to do all they could to build the right image for the general practitioner in Nigeria.

 

In close collaboration with Dr Pearson, the Faculty Board members drew up the syllabus for the Primary, Part I and Part II of the proposed Fellowship Programme having determined what type of front line doctor/general medical practitioner was appropriate for a developing country like Nigeria.

 

The Faculty resolved that such a doctor needed to have an adequate level of knowledge and competence in surgery, medicine, obstetrics, gynaecology and paediatrics to be able to deal with routine uncomplicated cases that need not be referred to the tertiary centers.

 

Such a doctor must however recognize the limit of his ability and know when to refer cases for more expert care.

 

The Fellows of the Faculty were to operate at the primary and secondary levels of the health care pyramid and there were 116 Fellows by examination as at September 2007. All who were still in Nigeria were based in urban centers or tertiary institutions. There was none in a rural/urban slum setting.

 

So, twenty-seven years after inception, the recognition the founding fathers sought has been elusive prompting a change of name of the specialty to Family Medicine and the formation of the Society of Family Physicians of Nigeria, SOFPON, comprising Fellows of the Faculty. But the specialists are not practicing where most of the families reside – rural and urban slums - the gap being filled creditably by the medical officers who were in the vanguard of the formation of the Faculty.

 

The disillusionment of the young doctors in the long training period and the insufficient training posts for the various fellowships of the NPMCN are serious deterrents to young doctors seeking to improve their skill and knowledge.

 

It is against this backdrop that four general surgeons who are in or have supported rural practice (Prof S K Gyoh, Prof E Alufohai, Dr A C Sagua and Dr O A Awojobi) decided to co-opt their junior colleagues in rural/urban slum practices for the inauguration of the Association of Rural Surgical Practitioners of Nigeria, ARSPON, that took place in Gboko, Benue State on 12th January 2008. Present at the inaugural meeting were Prof S K Gyoh, Drs E R Saliu, A O B Adenuga, M H Adabanija, A C Sagua, Dr F N Atsen, O J Fatokun, Tule Terver Zua, Dzer Hembe, O Ajose, A Idoga, Pevkyaa Yandev, A Ikparen, Yaji Samuel, Amah Anselom, A Rijam and O A Awojobi. Apologies were received from Prof E A Alufohai , Drs A O Windapo, J K Ladipo, (Mrs) M A Ladipo, and R O Tijani

 

One of main aims of the association is to provide training opportunities for doctors to acquire surgical skills in a short period that will enable them provide safe and affordable surgery to the rural/urban slum poor using appropriate technology that is time tested, scientifically sound and culturally acceptable. This will be achieved in collaboration with relevant training colleges and universities. A proposal has been placed before the National Open University of Nigeria, NOUN, for a course of study that will lead to MSc (Primary Care Surgery) and a Diploma (Rural Surgery) of the West African College of Surgeons is being pursued vigorously.

 

In recognition of the fact that hernia burden is still high in Nigeria, the Ibarapa Hernia Centre was established at Awojobi Clinic Eruwa in 2008 to provide opportunity for surgical skill acquisition. In this respect, the centre is collaborating with Operation Hernia, a UK-based NGO headed by Prof Andrew Kingsnorth and Dr Ravindranath R Tongaonkar of ARSI who generously donated 50 metres of Indian mesh for hernia repair. Operation Hernia has opened another front at St Vincent’s Hospital, Aliade, Benue State with the cooperation of members of ARSPON in the state.

 

The dichotomy that often exists between specialists and non-specialists in many medical associations in Nigeria has been removed in both the name and the constitution of the association wherein full membership is open to “All doctors who practise and promote the course of surgery in rural Nigeria for at least five years after full registration by the Medical and Dental Council of Nigeria, MDCN”.

 

We have had two national conferences held in rural practices of members: Dr A O B Adenuga’s Layo Model Hospital, Ikire, Osun State in 2008 and Dr J I Umunna’s Jasman Hospital Limited, Udo-Izihinite, Imo State in 2009. The first conference had an international flavor with the attendance of Dr Fassil Gebreegziabher from Tanzania. An innovation we have brought into conference literature is the publication in full the text of all the papers and guest lecture delivered on the occasion. This will constitute a resource for continuing professional education.

 

In November 2009, a 50-man contingent attended the joint conference of the International Federation of Rural Surgery, IFRS and the Association of Rural Surgeons of India, ARSI that took place in Pipalia, Rajahstan. During this conference, ARSPON was admitted into IFRS, Dr Awojobi was elected the secretary of IFRS and honoured with the fellowship of ARSI; Prof O O Ajayi and Dr J I Umunna were elected directors of IFRS. Nigeria will host the 4th conference of IFRS and will take place at Awojobi Clinic Eruwa in November 2011.

 

It is hoped that in the nearest future, Nigerians who live in the rural areas will have access to affordable and safe surgical care and the Family Physicians would move out of tertiary institutions and provide the necessary service and leadership at the primary and secondary levels where they truly belong.