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How to improve health services in Nigeria, by Badero

Badero

Badero

Dr. Olurotimi John Badero is a Specialist Consultant in Internal medicine, Nephrology and Hypertension, Interventional Nephrology and Endovascular Access, Cardiovascular Medicine, Nuclear Cardiology, Invasive and Interventional Cardiology; and also Peripheral Vascular Intervention. He performed the first trans-radial cardiac catheterization and coronary angioplasty at CMMC Hospital Mississippi, United States (U.S.). Badero graduated from Obafemi Awolowo University (OAU) College of Health Sciences Ile-Ife, Osun State. He continued his medical education in the U.S. He is a Fellow of the American College of Physicians; Fellow of the American Society of Nephrology; Fellow of the American Society of Diagnostic and Interventional Nephrology, Fellow of the American Society of Nuclear Cardiology; Fellow of the American College of Cardiology and Fellow of the Society for Cardiac Angiography and Interventions. Badero is a recipient of many awards. He is board-certified in six different specialties and is currently one of the only fully trained and board-certified cardio-nephrologist (combined kidney and heart specialist) in the world today. He is also arguably one of the most certified physicians in the world. Badero is the Executive Director of Cardiac Renal & Vascular Associates. Mississippi, U.S. Badero in this extensive interview with DOLAPO AINA during a recent visit to Lagos said the standards of hospitals in Nigeria have improved. Badero, however, identified the many challenges faced by the health sector even as he made recommendations on how to improve services.

Why did you decide a path in this profession?
I have been asked this interesting question several times and I still pause every time I’m asked. I never wanted to be a doctor. I had two professions in mind. I was quite good at fine arts and I believed art was a very good form of expression. I still do. We all have fluid minds iced in the quiet of our thoughts that need to be expressed to the outside world. Art is a very good medium for that expression because you don’t have to be politically correct. You are free to express yourself. So, I liked art. I also liked mechanical engineering but my father wanted me to be a physician. I rejected the idea initially and after a long discussion, arts came off the table and I maintained I would study engineering, which he still was not happy about. He eventually called me into his room one evening and very candidly told me how much he cared and wanted the best for me. He mentioned if I took his advice and studied medicine, I would do something special and his blessings would be with me. That obviously was the turning point because I wanted my father’s blessings and I gave in to study medicine. Initially, I was not an ideal student because I would skip classes and sometimes not show up for tests etc. You know it is easy to choose between right and wrong. But what is more difficult is choosing the wrong that is more right. Gradually towards the end of my clinical years in medical school, I started investing myself in the process and it became fun. I believe life is like a coin, you can spend it any way you wish but you can only spend it once. I had to understand that I am the author of my own story and to do that, I had to stay truthful to my youthful energy and make the best out of my life.

You are the only medical doctor with an expertise as the only combined cardiologist and nephrologist in the world. How did that come about?
I think it was purely by divine intervention and it was not a task I set out to accomplish or achieve. Most of my training during my career have been fraught with lots of challenges at every stage; right from primary school, trying to get into a private school, leading up to secondary school, university, and finally post graduate training. I made it through medical school and got to the US, where I faced even stiffer challenges at every stage of my career. I did not have the opportunity to train as a cardiologist initially but I did not let that deter me because I believed in God and if you believe in God and stay true to yourself, you will eventually arrive at your destination. You know happiness keeps you sweet; trials keep you strong, sorrows keep you human; failure keeps you humble, success keeps you glowing but only faith keeps you going.

I persevered and had to train, first as a nephrologist and an interventional nephrologist. The opportunity to train as a cardiologist would later present itself and I took it. This meant spending more years, which obviously had its challenges. But every morning I tell myself I have two choices; continue to sleep with my dreams or wake up and chase them. I decided to do the latter. I eventually found myself in the field of cardio-nephrology and when I discovered I was the first to do it, I was quite surprised in a nice way.

How challenging has it been?
To say the least, it has been quite challenging. First of all, coming from Nigeria, there are lots of things you have to get used to. Nigeria is a tropical country, while America is in a temperate zone. Getting accustomed to the weather, can be challenging at times.

Understanding the different culture can also pose a challenge. You know, just the way people do things, the language/accent is also very different. The food is also different and cheap and as you know, can be fattening. As a physician I learnt fairly quickly that medical practice in America is evidenced-based. Medical practice In Nigeria is not entirely evidenced based due to no fault of the doctors. The lack of funds to implement some key research in various fields is always a constant reminder of the developing process, albeit slow, of the Nigerian state. Some of the evidence-based trials that influence the medical practice abroad were conducted on predominantly Caucasian cohorts and we have to extrapolate and apply those results to our African patients here in the tropics. As a black physician in a field dominated by Caucasians, it can be quite challenging as well but you know you cannot let your background put your back to the ground.

I was fortunate and blessed to train in very good institutions with high expectations. I try to look in the mirror daily and see the person I am up against. I am up against no one except myself because you are your own greatest critic and greatest supporter. I have expectations of myself quite different from that of the institutions or people I work with; and that started from a young age. I noticed that the expectations other races have of us Africans and not just African Americans are way below our intellectual abilities. But I can tell you that is rapidly changing. You know many people still see Nigeria as a dystopian society where luxury is a stranger to many and poverty a constant companion. That bothered me initially, but then, I realized the burden of the brutalized is not to comfort the bystander. So I began to see the obstacles not as challenges but as opportunities to make a difference. It became much easier when I saw things from that perspective. A stone can be perceived as a stumbling block to someone and as a stepping block to another. Remember, it is not what you see but how you see what you see. Those were the kinds of challenges I faced.

A while ago, you were recognised and awarded at the United States Congress. How did that come about?
That was a National Merit Award given to me by the United States Congress. I was honoured and humbled at the same time but thankful to God for the recognition because it is a huge award. We are nothing of ourselves but we are who we are only because of the grace of God. You really do not achieve anything by yourself. Everything is collective. The award is shared with people that have invested in me. That includes my teachers, friends and family. I could not have completed my training in the U.S; without the foundational medical training I had at Obafemi Awolowo University, which by the way; was relatively inexpensive. I don’t take that for granted and I don’t think anyone should.

Did the award propel you globally?
Quite interestingly, a lot of people are not even aware of the award because it has not been publicised and really it does not need to. I think this is largely due to my personality; I am not one that likes publicity. I am really a private person. I believe whatever God gives you, is really not for you but to help others.
If the award inspires someone, or a group of youth, or a society then I am happy to accept it. I would not say it has made much of a difference. You know some people say to excel and to know how to show it, is to excel twice. I don’t know if I echo that thought but hopefully, someday, someone would get inspired probably another Nigerian who would be true to his or her cause and diligent in what he or she does.

How long have you been in the medical field? And how long have you been a combined cardiologist and nephrologist?
I have been practising medicine for close to nineteen years since I graduated and it has been an interesting bittersweet journey with its ups and downs. But in all, I remain grateful for the opportunity to take care of the sick and put a smile on people’s faces. I always believe that the wealth of a creative mind lies in the ability to make a difference in people’s lives. The ability to make a difference between health and sickness is one of the greatest wealth you can have.

Being a cardio-nephrologist is exciting, since the heart and kidney are closely related. I believe cardio-nephrology should be a specialty on its own to train people in these two fields. I have been a cardio-nephrologist for sometime now and the journey thus far has been rewarding. When l practiced as a nephrologist, I enjoyed taking care of kidney disease patients but I realised that many of the patients were dying from heart diseases. It was quite challenging taking care of these patients since they died from something else which I had no control over. Something entirely unrelated to the kidney.

After I became a cardiologist, both specialties put me in a distinct category because I could evaluate patients with an in-depth perspective. That gave me a real advantage as opposed to just being a cardiologist or nephrologist alone. In that regard, it has been very rewarding because caring for patients is quite different when you have both backgrounds. I see things differently (which I might not have seen in the past) and it has translated into good care and good results. The patients recognise that and that for me is key.

What makes being a cardiologist different from being a nephrologist? Any differences or are they inter-related?
They are inter-related but then again there are subtle differences. There are not a lot of subspecialties in Nephrology compared to cardiology. The Nephrology specialty includes sub-specialties like transplant nephrology and more recently interventional nephrology. The Cardiology specialty includes sub-specialties like non-invasive cardiology, interventional cardiology, electrophysiology, heart failure, cardiac transplant etc. The Cardiology specialty has been around for quite a while and more researches have been performed in cardiology than most other specialties. There are also more cardiologists in the world than nephrologists. The heart is a very central organ. Although all organs in the body are important, we do know that once the heart stops, everything stops.

The field of cardiology is more procedure driven compared to nephrology, which is another major difference between the two. Most kidney disease patients die of cardiac diseases, so invariably they need to be seen by a cardiologist as some point. Kidney disease is considered a cardiovascular risk equivalent; meaning its severity can almost be compared to someone with established heart disease.

As a Nigerian, what are the positives you have noticed in the health sector since you left Nigeria?
First of all, there has been an increased awareness and improvement in the utilization of healthcare within the general populace. Some of the medical resources that were not available 16-20 years ago are now available. The standards of some of these hospitals have also improved. We are not completely there yet but there is an upward and positive trend that should be recognized. Sixteen years ago, we did not have a comprehensive laboratory (I believe we have one now.) That has improved diagnostic abilities, treatment and therapeutic options. I also think the government is beginning to have a stronger presence in the medical sector as well as seeking to collaborate with private investors.

There are now more Public Private Partnerships, which were never really in existence before. That is quite important in the development and sustenance of the health sector in Nigeria.

What are the negatives you have noticed in the health sector in Nigeria?
I am sure there are negatives but I don’t focus on negatives or problems. I try to focus on solutions. In Nigeria, we focus too much on problems and we become problem-oriented. I am of the opinion that we should try to look for solutions to the prevailing problems at the moment. But having said that, I would look at the challenges as exactly what they; challenges and not as negatives. There is a lot of bureaucracy that needs to be addressed particularly when dealing with the government and even individuals. You know everyone in Nigeria is a V.I.P and we don’t fail to make others realize that. That amuses me really because the emphasis is never on the person but on the people or the society collectively. We should learn to de-emphasize ourselves realizing that the institution is bigger than the person. We have a threshold model of collective behaviour here in Nigeria that is quietly understood and certainly needs to be changed.

There should be a platform for knowledge and skills transfer on a continuous basis. There should be a medical bridge between Nigeria and the developed countries through its own nationals who have acquired the knowledge and skill set abroad. I believe that the creed of knowledge and exchange of ideas, we should uphold as an absolute in itself in any societal construct and our society is certainly no exception.

I also believe that power is very central to the viability of any sector in a country. This has been the leprosy of Nigeria. The financial, agricultural, science and technology and healthcare sectors depend on power. Small businesses depend on power. Everything depends on power. For example, if you come to Nigeria with the brilliant idea of setting up a private medical enterprise (hospital or diagnostic centre.) You will invariably spend a lot of money generating power for your business, as the power supply from the government is epileptic and sometimes comatose. That expense is an overhead that would eventually be passed on to the patients. So, you try to take care of people who really don’t have funds due to non-existence of a robust health insurance system and you spend a lot in the process. If you don’t transfer that overhead to patients, you would eventually run out of funds and your business will die an untimely death and be buried in the annals of history. Power has been, and continues to be one of the challenges of the healthcare institution in Nigeria.
Just recently I lost a very close friend Dr. Emmanuel Adewumi to kidney failure just because of lack of power supply. He showed up at his regular dialysis centre in Ondo but could not be dialysed due to overworked and broken down generators. He travelled to another town where there were not enough machines for dialysis. He eventually travelled back home to Ondo.

After many phone calls, I got through to a colleague of mine Dr. Yomi Okunola who was really helpful. He was able to get him a slot in the dialysis unit at OAU hospital, Ilesha the next morning. My friend would eventually not make it to the dialysis centre as he died in the early hours that morning while getting ready to travel to Ilesha. Quite simply the system failed him. He was a brilliant doctor and a great person and will be surely missed.

Not too long ago I also lost my niece to kidney failure while awaiting plans for kidney transplant. That was quite shocking as well.
Some years back as well, I lost a very dear friend and gem, Mrs Juliet Dixon to kidney failure. She was a lawyer and the head of Alumni department at OAU, Ife. She was such a delightful, caring and generous person and her life was cut short by kidney failure. It is painful to think of some of these losses.

Furthermore, we also need some form of regularisation of healthcare in Nigeria. The difference in cost of medical care for the same condition at different hospitals should not be astronomically different. This can lead to differences in standards of care. I am not advocating for institutions not to make profits and I am certainly not saying it is wrong for them to do so, but I think to a large extent, there should be some kind of regularisation that makes it easy for the standard and cost of healthcare to be uniform across the country. This will definitely help the masses and not create a tier or class system; which I think is very prevalent in Nigeria.

What medical innovations do you believe the health sector in Nigeria is in dire need of?
From the cardiology point of view, taking care of patients with heart attacks and heart diseases, requires expensive equipment for diagnosis and treatment. I am not certain if Lagos State currently has more than one functioning cardiac catheterisation centre. I know of the cardiac and renal centre in Gbagada, which I visited recently but unfortunately, there have been some financial challenges with that institution. I am aware there were issues with some of the expensive machines not working due to incessant power supply. I am also aware it cost them well over N5 million monthly to run their generators in a bid to generate their own power. Eventually that is not sustainable and these generators will pack up. I know of a centre in Ogun State as well. I doubt if we have more than four fully functional cardiac catheterisation laboratories in a 36 state Nigeria. This needs to be addressed because heart disease kills more women than all cancers combined together. These procedures save lives but you cannot perform a procedure without the necessary equipment, the same way a farmer cannot farm without a hoe or cutlass.

In America, people rightfully talk about black lives matter. Guess what? Here in Nigeria, Nigerian lives should matter to us. We might not have gun violence and killings to the extent they do in the US, but we have poverty and lack of affordable healthcare that kills Nigerians sometimes faster than guns do.

We know that cardiovascular disease is the number one cause of death in the world and has been for decades. For physicians to take care of this number one cause of death, we need to have the equipment as well as the manpower and skill set to do so. Nuclear medicine/nuclear cardiology is pretty much none existent in Nigeria. That is an aspect of cardiology that also needs to be developed. Nuclear cardiology involves diagnostic testing using nuclear agents. With this technology, you can identify patients with heart disease as well as patients with blocked arteries way before a fatal heart attack happens.

The sub specialty of cardiology called electrophysiology takes care of patients needing pacemakers and internal defibrillators etc. This specialty is marginally existent in Nigeria. Patients whose heart muscles are very weak are prone to sudden cardiac death. These devices prevent sudden cardiac deaths and help save the lives of these patients.

Regarding the practice of Nephrology, we now have dialysis centres able to take care of patients with kidney failure requiring dialysis. While this should be applauded, more work needs to be done. There are not enough of these centres unfortunately, and where these centres exist, there are not enough machines and certainly no constant power supply to run them. These centres have no choice but to generate their own power, which cost money.

During my last trip, I visited the Healing Stripes Hospital Centre built by the RCCG City of David parish under the pastoral leadership of Idowu Iluyomade and I must say I was quite impressed. They have at least ten dialysis machines while some of the teaching hospitals in Nigeria have only three. They have a surgical centre as well performing life saving operations. The cost of dialysis treatment at Healing Stripes Centre is heavily subsidized and sometimes, even free as some of the church members adopt patients and pay for their care. I understand the church even raises money at times to render free care to all these patients during that period. Now, that is commendable and worthy of emulation.

There are affluent Nigerians who are philanthropists that do care deeply about the well being of this country. They can fund dialysis centres and subsidise the cost of dialysis. The treatment is quite expensive in Nigeria and is not really sustainable on a chronic basis and renal failure is a chronic condition. In developed countries, the government funds dialysis treatment three times a week.

In Nigeria, patients who cannot afford thrice a week treatment; go a whole week without treatment due to lack of funds and we know some don’t even make it after a week of missing treatment. I also lost a niece to this disease while waiting to get a kidney transplant.

Normal kidneys don’t function once a week, so can you imagine once a week dialysis? I don’t think I would be wrong if I assert that there seems to be a growing epidemic of kidney disease in Nigeria today. I think the government should really take a closer look at the rising incidence of kidney failure in Nigeria. Currently, twenty percent of deaths in Nigeria are kidney related.

Surgeons are able to create arterio-venous fistulas (connection between and artery and a vein for dialysis) but unfortunately, some of these accesses fail prematurely because of the absence of an interventional Nephrology program and specialists who can perform regular access surveillance and treat problems before the fistulas fail.

What you have is a situation where lots of patients get artificial tubes called dialysis catheters in their necks and these tubes are prone to infections. These tubes are typically placed in the heart through veins in the neck, so an infection of the catheter can potentially spread to the heart, infecting the heart valves leading to death.

I was at the Obafemi Awolowo University Teaching hospital (my alma Mater) last year and I learnt that these catheters are quite expensive and most patients cannot even afford them. Some of these catheters cost fifteen thousand Naira for one. One dialysis session in Lagos can cost close to thirty thousand Naira and should be done three times a week which is nearly hundred thousand Naira per week. Add all that up in a month and the total expense equals the salary of a consultant doctor in Lagos. That is the reality we face.

With regards to kidney transplantation, there are few transplant centres in Nigeria. Those that have the funds go to India to get kidney transplantation procedures. We should have a robust transplant program in major regions in Nigeria so people don’t have to travel from one region to the other.

I don’t see a reason why Nigerians should travel to these countries if we have an effective centre with the right resources and manpower at relatively affordable rates with standards that are globally accepted.

Where is the business perspective to all you have said?
There is always the business angle to anything. As a doctor, we are not typically trained to look at the business side of medicine. We are trained to take care of patients. As an entrepreneur, I had to learn about the business of medicine. In medical school, nobody teaches you the business of medicine or the legal aspect of medicine. You are only taught the medicine of the medicine. When you begin to practice as a physician, you learn the legal aspects of medicine and if you own a practice, you quickly learn the business aspects of medicine. There is a business aspect to everything we do.

With people comes finance because the strength of finance is always in the strength of numbers and that means people. That is why China is very strong today, because of its population. Anytime people utilise resources or services, or buy goods, there is some form of business venture. If Dubai can have medical tourism (a business aspect that generates a lot of money because people troop to Dubai for check ups etc); I don’t see any reason why we cannot have medical tourism in Nigeria. We have the culture, we have the food, we have the expertise, we can build the infrastructure, get the experts and we certainly have the flamboyance and guess what? People are curious about Nigeria so there goes your medical tourism.

We have approximately 170-200 million people in Nigeria. That is a lot of people. Our population is one of the reasons why we have been considered as an emerging market. With a vast population, the utilisation rate of any resource is going to be high. There is a business aspect of medicine that can be tapped into in Nigeria because if we have centres that provide adequate healthcare then people do not need to travel overseas to get their healthcare. They stay back in Nigeria and generate financial revenue, both for the government and private sector. That is something that definitely should be looked into.

I think there should be more public private partnerships. You know, historically, we have had a lot of shell hospitals (big infrastructure that have become non existent within ten years) in Nigeria. We have spent lots of money putting these massive structures in place with no maintenance culture and no real vision. In the end, you give the people no choice but to go some place else.

Our immediate need is not infrastructure. We need appropriate skills to be harnessed here locally, we need to reverse brain drain from developed countries, we need manpower and we definitely need to infuse a maintenance culture into our disposition and maintain what we already have. There has to be continuous knowledge transfer and training of our people to ensure proper maintenance of that standard.

You are making giant strides in the West but are you making impact in the health sector in Nigeria?
I grew up in an era of political contestation fragmented by a dominant military disposition, where staid political discussions were had everywhere. The military hegemonic oligarchy used to be once a dominant political construct in Nigeria and I am glad that has faded into the dust of political history. That has now become a distant memory whose existence is difficult to imagine.

Many years ago, we did not have a stable political disposition and that did not foster an enabling environment for a thriving healthcare system. It also did not encourage people in the Diaspora to come back home. These are the so called “brain drain” folks with the expertise that have been acquired abroad, many times through painful sacrifices (let‘s not forget). Now many of these folks want to come back to Nigeria. They want to impart the knowledge they have acquired and ultimately make a difference. I’m sure you’ll agree that can be difficult when safety is a concern for them and their families.

I have made several trips back home in the last one year because I feel a need to make a difference and I believe the time is now. My medical journey started here in Nigeria costing relatively less than what it would have cost if I had attended medical school in the U.S. I believe the circle of knowledge cannot be completed if you don’t come back to the staring point and I certainly believe in giving back. I want to use the God-given ability and expertise I have been blessed with to help the people. I don’t think it is expedient using your knowledge to help others and not helping your own people; people that helped with your foundational experience. I have tried to initiate talks with State and Federal Government officials as well as private institutions to explore areas where my expertise can be utilized. This is an ongoing process that I remain passionate about. It can be admittedly discouraging at times but I look beyond that and focus on the goals at hand.

I am also involved in medical mission work and have done work in Santa Domingo in the Dominican Republic as well as in other parts of the world. That’s another passion of mine and is something I would like to see here in Nigeria as well.

What book are you currently reading?
It’s called The King James Bible.



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