“Rural surgery and Operation Hernia: reflections on a truly surgical elective”

Phase 3b MBChB
University of Sheffield

Ceremony in Eruwa
Ceremony in Eruwa

At the beginning of my third year of medical school, I was jokingly challenged by a general surgery SpR that noticed my unusual interest for hernia operations, to have a look at the Operation Hernia Foundation website. So I did, and it has been ever since that I planned to join this NGO for a mission. When I planned my elective, I wanted to be exposed to general surgery, to travel to a developing country and to join a recognised charity. So the Operation Hernia Foundation projects seemed perfect! I took the courage and wrote to Prof. Kingsnorth, President of the European Hernia Society and in charge of recruiting volunteers for the Foundation. Not only I was allowed to join one of the teams, but I was put in contact with Dr O. Awojobi, Project Coordinator for the project in Nigeria, to be given permission to spend some time in his clinic in Eruwa, prior to joining the mission. I also spent the initial part of my elective in my own town, Sheffield, to learn some general surgery beforehand, to be sure that I could make the most of the experience.

And so it happened that in July I travelled to Nigeria, a few lectures on rural surgery in my bag to prepare me for the adventure, and a book on surgical techniques to study. Leaving the UK I thought I was prepared for what I would find in Nigeria: I had recently been exposed to general surgery in the Department of Colorectal Surgery in Sheffield, had some previous clinical experience and I had travelled to Africa before.
However, from the moment I was collected from the airport in Lagos by Dr Awojobi, I sensed that I was embarking in a very emotional journey. When, during the quite long drive to Eruwa, Dr Awojobi introduced me to some important and proud moments of the history of his family (Fig 1) I realised that I was being welcomed in his team and I felt a sense of honour that seemed positively old fashioned.

Scrubbed in an elective surgery with Dr Awojobi
Scrubbed in an elective surgery with Dr Awojobi
The team of the satellite mission in Isotan
The team of the satellite mission in Isotan

The following day I was introduced to the work in the clinic. Dr Awojobi s clinic (Awojobi Clinic Eruwa, or ACE) is a private hospital in the public service , and offers not only surgical treatment but also preventive medicine, primary care services, and medical treatments. But Dr Awojobi is primarily a surgeon, and of a special type: he is a rural surgeon. As such, he offers in his clinic a huge variety of surgical treatments, to patients that present with very complex and advanced diseases. Once over the surprise in seeing diseases such as a 6.5 Kg uterine fibroid, I still found difficult to adjust to the variety of surgeries offered; only in my first day the operation list involved: a myomectomy, an ORIF of a femur that had been shattered by a pellet gun 6 months previously, two prostatectomies and the debridement of a skin ulcer involving the whole forearm: gynaecology, orthopaedics, urology and plastics all in one day! I started wondering how it was possible to perform all these different surgeries, and what I was learning from this experience. Dr Awojobi, after long days spent operating, patiently spent long evenings discussing these concerns with me, reminding me that everything needs to be seen in perspective, that there are at least two sides to every coin. And indeed after some time, I had the proof that, as long as the basic principles are respected, things work even if they are done in a different way, their application suiting the local environment. After a while I actually started enjoying and admiring the innovations introduced by the doctor in the attempt to keep providing affordable services to his community, like the suturing needles obtained from sterilized fishing thread inserted in a sterile injection needle, or the manual centrifuge to analyse the pack cell volume (PCV). Where I felt frustration I was reminded once again of how it is necessary to make a structure work with the resources available: in the rural environment ketamine is an acceptable general anaesthetic and relying purely on clinical signs and symptoms even in the acutely ill patient is the substitute for the lack of complex blood investigations.

I also realised after a while that most of my questions and queries come from missing the bigger picture ! I kept concentrating on small details instead of considering the enormous infrastructural efforts that had been put in place long before I joined the clinic, that has free flow of water all the year round (thanks to wells that collect water in the rainy season), and an alternative energy supply in the form of a generator, that can be activated every time the national supply stops (and it happened in the middle of the night in the middle of an emergency operation!). This contrasts dramatically with the situation for example of the local governmental Hospital which I had the honour to visit, where there is no running water, only one toilet for patients in the whole hospital, and a desolated A&E Department with no medical equipment. So I appreciated even more the efforts made by Dr Awojobi to provide what is a very high standard of care in his Hospital.

When the Operation Hernia mission started in the final week of my elective this structural setting become even more apparent, as for example thanks to the generator, the volunteers had the chance to enjoy air conditioning in theatre (which is different from the one used by Dr Awojobi).

In contrast to Dr Awojobi that works alone, as the only physician (and surgeon) in the clinic, the UK team was composed by 8 members: two surgeons, 3 nurses, an anaesthetist, an ODP and me, delivering in the middle of Nigeria in the rural setting a standard of care comparable to the care offered to patients in the UK.

Operation Hernia team with Mrs Awojobi and members of her team
Operation Hernia team with Mrs Awojobi and members of her team

The Operation Hernia experience was fantastic, it was not only very productive in the number of surgeries performed but it was an excellent example of team work. After the first exhausting day spent unpacking the many boxes of material brought from the UK, the team performed 50 surgeries in five days of hard work. I was not the only student, as a local doctor participated in the training, under supervision of the surgeons in the team. I had the chance not only to see patients preoperatively, but also to scrub in and assist in 31 operations, receiving one to one teaching by Mr Hanafy, a very experienced consultant surgeon. It is difficult to explain how important and inspiring this opportunity is for a medical student.

In the Operation Hernia theatre between cases, with a local doctor in training and baba Karim, practice nurse in Dr Awojobi s team.

So when the team left, I resumed my long evening discussions with Dr Awojobi, and asked his thoughts about the differences between the Operation Hernia work and the work in his clinic. He explained that the local community has benefited greatly from the services of the Operation Hernia, but that some costs related to it (such as the cost to operate the air conditioning unit or to use the commercially available mesh for hernia repair) at the moment would make such structure unaffordable in the long term, were he to use the same methods. But Dr Awojobi is a very resourceful man, and he always strives to find a solution to every problem, for the benefit of his community and for the pride of the scientific African community, and so he will be looking to continuously improve the service offered, but at an affordable price.

But the Operation Hernia Society mission and ACE do not only stand out for their differences. They represent a very successful medical collaboration, in which the NGO, while possibly providing training for its own members (such as it was for me as a UK medical student) supports the local population both in terms of patients treatment, which can be free or cheap, and health professionals providing training and updates on clinical knowledge and technologies. The most successful NGO project is indeed the one that leads to the independent development of a health system locally.

It is impossible to recount all the activities and experience accumulated in Eruwa: for example I was involved in the retrospective collection of data on hernia repair performed with the use of sterilized Indian mosquito nets, I learnt to perform USS on pregnant women under the supervision of Mrs Awojobi (wife of Dr Awojobi, and a qualified radiographer and great teacher), met Nigerian students and doctors in satellite projects organised by Dr Awojobi and even met a real King!

With Dr Walker, pioneer of HIV treatment in Nigeria that collaborates with Dr Awojobi in providing HIV medications to the ones in need (top), the team of the satellite mission in Isotan (middle) and the Operation Hernia Team with Mrs Awojobi and members of her team (bottom).

When I left Nigeria, I felt that I had gained much more from this elective than clinical and surgical experience, which was excellent both in terms of hours and quality. The most important aspect of it was to receive the invaluable gift of finding excellent role models of professionalism and work ethics.

Cristina Frezzini