by Seye Abimbola
To have a medical school is an expensive, audacious undertaking anywhere in the world. From very humble beginning at the Yaba Medical School which produced 62 doctors in 18years (1930-1948) Nigeria has made unparalleled achievement in training medical manpower of all cadres. Nigeria has about half of all the medical schools in Sub-Saharan Africa, all nestled within universities, all with accompanying teaching hospitals. My last count was at least 25 medical schools in Nigeria. Each medical school produces about 100 doctors each year. Medical education has flourished in Nigeria in spite of several obstacles mostly due to the doggedness of their founding fathers and those who subsequently took over, their pragmatic willingness to settle for less, adapt to difficult realities, and jettison juvenile dreams while they continued to keep their eyes on the beatific vision of the heaven of sophisticated high tech medicine in teaching hospitals.
Two years ago I did my national service at the medical school of Ebonyi State University, Abakaliki. I was highly impressed that Ebonyi was confident enough to have a medical school. I am from Ondo and Ekiti, arguably two of the most educationally advanced states in Nigeria, with no medical school between them – not even one run by the federal government – because it too expensive. Physician and writer Lewis Thomas who was dean at different times of the medical schools at Yale and New York University once observed that “the annual budget of some medical schools matches or exceeds the operating budget of all the university.” Beyond being impressed, I was also puzzled. How does Ebonyi manage to run a medical school, while Ondo, though an “oil producing” state could not afford one? I was keen to know how much the medical students paid, how the medical students were recruited, if there is a preference for indigenes of the state and if non-indigenes paid more. We are big thinkers in Nigeria and medical education seems to be one area where our audacity has paid off at least to illustrate what we can achieve as a country.
The beatific vision of sophisticated tertiary care in Nigeria is largely inspired and sustained by looking to the West to provide models. Thomas wrote in 1983 about pre WWII US medical schools which were “small affairs by today’s standards” with a “small and relatively inexpensive clinical faculty” and teaching hospitals were “supported by the local community.” Like US universities at that time, Nigeria’s first two medical schools (Ibadan and Lagos) also shared a fixed proportion of their general endowment with the medical school. The University College Hospital, (UCH) Ibadan and Lagos University Teaching Hospital (LUTH) grew rapidly early post-independence as expected for institutions charged with the education of a new nation’s first indigenously trained professionals. Like the pre WW II medical schools in US, things were pretty small scale and operated at an internationally competitive level so much that long after UCH was completed in 1957 it was still regarded as one of the best within the British Commonwealth and continued to be a prime research centre in the world for much longer, reaching its global heyday in the late 70s and early 80s.
The US medical schools were often partly privately owned and they actively sought funds on their own, did not require the university to pay academic physicians who earned their living in private practice. The economic boom in the US following WWII altered the quietude and the National Institutes of Health (NIH) drove a massive revolution in research funding. In the UK, there was renewed confidence of the power of research to solve health problems which spread through the British Colonial Office to Africa with strong influence on the direction of “tropical medicine.” The period was also when several UK colonies in Asia, especially India gained independence, freeing colonial researchers and funds for other parts of the Empire. Hence the medical school in Ibadan, founded in 1948, flew on the wings of UK and US expatriates, ideas, funds, inventions, initiative and influence. For its first eight years, medical students in UCH only had their preclinical education in Ibadan; the clinical training was in London. These were to become the group of professionals that would shape medical education and practice in Nigeria as they did well to establish other medical schools post-independence inspired and supported by governments, regional, state and federal. It is kudos to successive Nigerian governments that the UK model was imported, if indiscriminately for medical education, practice and research in Nigeria. While there were and still are no rich grant awarding institutions in Nigeria, the government took it upon itself to fund every aspect of the academic enterprise in Nigerian universities, and by extension, medical schools after the inevitable withdrawal of British researchers and funds.
To my relief, there was open preference for the indigenes of Ebonyi in admission and indigenes paid less. That I often had to make arguments in support of this policy shows how we have been so spoilt in Nigeria that we are blind to the economic implications of health care and medical education. If the state government devotes scarce resources to the running of a medical school, then her indigenes are to be primary beneficiaries. The staffs of Ebonyi State University Teaching Hospital were on strike for four successive months during my service year, agitating to be paid the same amount as their colleagues in other, mostly richer states. The question then is where we should expect the money to come from? Is it from a government that might be doing too much already? From the students who seem to be the immediate beneficiaries of the medical school? The community that benefits from the teaching hospital that owes its existence to the medical school?
Fifty years on, for academic medicine to survive, improve quality and ensure growth, the federal and state governments need to rethink their funding policy. Like the old inexpensive US medical schools, medical schools need to actively seek out grants from philanthropists locally and internationally, and involve all stakeholders: the students, their parents, the host community, alumni, and the sponsoring government. More importantly, it is time to cast our eyes to a new god, a new vision; that often ignored god, the one within. The best newspaper article on Nigerian medicine I’ve read this year was a feature by NEXT journalist Allwell Okpi titled Your Friendly Neighbourhood Pharmacy. The author stated that “some of the pharmacies have served their neighbourhood long enough that they are now trusted sometimes more than hospitals” and “their proximity makes them the doctors next door.” What we have in Nigeria is a tertiary care based system where doctors stay in the hospitals, often remote and expensive, for patients to come in and consult, a relic of the colonial history of Nigerian medicine where the development of services started mainly from the high places, the holy of holies of tertiary care – UCH and the ones that followed. We have abdicated our responsibility for primary care to the Friendly Neighbourhood Pharmacy. In planning for the Nigerian health system we ignore these most important if informal and untrained health providers at our peril.
The generation of medical schools that were started post-independence saw the flaws in the existing system and tried to found medical schools on a philosophy that put primary care and the community first with fresh and innovative ideas. Ibadan, as an afterthought in 1963 started a community project in Ibarapa. However, it was the medical school in Ife (1972) which pioneered the movement to organically integrate primary care and the community into medical education, which was soon taken up by Ilorin (1976), Ogun (1982), Bayero (1985), and Maiduguri (1990). The Ife programme was to inherit and build on the work and legacy of David Morley within the community zones that were marked for the Ife medical school, and went on in its early years to conduct ground breaking research especially in child health that would directly influence WHO and UNICEF policies. The Ilorin programme was adopted by the WHO as a model for community based medical education. However, most medical schools did not catch on, and the early fervour was not sustained, not least because soon after Ife started graduating doctors who were called “community doctors” the medical school slowly and quietly abandoned its earlier idealism and community, preventive and primary care focus for a big teaching hospital after the model it had struggled with distinction to avoid.
We witnessed significant shift toward primary care during the golden Olikoye Ransome-Kuti years when Nigeria recorded some of the highest immunization rates in the world. The progress made in those years could not be sustained partly because they were achieved through means that were not owned by the communities. Nigeria is dotted with failed primary heath care centres. If people have structures and systems to which they have grown to be loyal and accustomed, we must opt to build health systems around them, à la the Friendly Neighbourhood Pharmacy. The future of Nigerian academic medicine is in the community, and we must sustain our innovations this time around. The first 50 years have taught us lessons about what works and what we are able to achieve. We have looked outwards to the West with a steady gaze for far too long. It is time to innovate from realities at home. The running of our medical schools and health systems will continue to be increasingly expensive and hinder access, if we choose to remain in the past. The challenge is upon us to see with new eyes. The god we look to the West for, that beatific vision can well be created in Nigeria, but differently.