A recent visit to a public health centre by Southsouth Regional Editor, Shola O’Neil ignited a deep interest in probing the ordeal of kidney disease patients and the challenge of treating them . His finding reveals an alarming escalation in kidney-related disease, which transcends all ages and flipped known norms about the disease. Specialists who spoke on the looming epidemic deconstruct how the rise in the face of an unprepared public health system across Federal and state facilities, brain drain, and low morale in the sector spells doom for patients and their families.
The University of Port Harcourt Teaching Hospital, UPTH, Port Harcourt, Rivers State, like most government hospitals in Nigeria, is usually a beehive of medical activities. The emergency unit on Thursday, September 8, was swarming with patients many of whom perched on makeshift beds.Others had spent days on stretchers because of unavailability of beds in the wards. The flow appeared to be endlessly turning the transitory unit into an open ward.
In that milieu, a young man in his 20s sat on the floor in a corner. His legs were swollen and he had an inimitable sickly mien about him. A middle-aged woman stood over the effete youth, a mask of worry covered her tired face.
“He is suffering from kidney failure”, one medical personnel whispered in response to the curious look on this reporter’s face. “Yes, it is (kidney failure)”, another volunteered in response to the reporter’s look of disbelief. “We are seeing more of these cases recently; it is on the increase. Look around and you will see,” she mumbled and trudged away, with her oversize scrubs adding to the cacophony of sound.
The reporter, indeed, looked around and what he found truly frightening.
Across health institutions in Delta, Rivers, Abia and Lagos States the situation is grim. Many patients, including teenagers, are being diagnosed with kidney diseases.A health official claimed t the disease accounts for up to 40 per cent of referrals to tertiary health institutions across the country.
Four years ago the National Association of Nephrologists (NAN) warned about the steady rise in renal diseases. 25 million Nigerians (about 14 per cent of the estimated 180 million population),it said, suffer from kidney related diseases. Nephrologists (experts in the treatment of kidney diseases) say the situation is more worrisome today.
“More people in the lower age bracket are coming down at various stages; most do not even know it yet because screening is rare; people hardly go for medical checkups until the signs become unmistakable. Chronic Kidney Disease is about the last stage and that is where you see the symptoms that you talked about in the young man,” a source at the hospital said.
“Usually, high blood pressure, diabetes, and environmental pollution are the primary causes of CKD. The recent spike can be traced to increased cases of hypertension resulting from economic hardship, social pressure, and lifestyle and drug abuse by youths. These are just a few of the causes,” the sources added.
Dr Akpowaye Akpomiemie, a consultant nephrologist at the Federal Medical Centre, Asaba, Delta State, provided more insight into the trend: “Quite a number of things are responsible for the increase: infections and drugs/medications, we have quite a number of body creams and soaps that contain harmful chemicals these days that were not available to us (in the past).
“There is also exposure to environmental pollution such as crude oil spills and other environmental conditions, metals, hard metals, cambium, chromium that lead to enteritis and kidney diseases. Those are some of the reasons that may be responsible for the increase in kidney and other chronic diseases. Even global warming is a factor.”
He noted drug abuse, excess alcohol consumption and undue use of painkillers overwork the organ, noting that although most metabolisms (of drugs and other substances) in the human body occur through the liver, the elimination of those wastes is mainly done through the kidney.
Dr. Simon Musa Tada, Director, FEAT Kidney Foundation, blamed poverty, lifestyle and persistence in traditional beliefs. “Poverty is the reason people cannot afford hospital; instead they go to chemists and babalawo (witch doctors) and drink all forms of drugs (concoction) that destroy their kidneys.”
Harping on the effect of crude oil exploitation and exploitation and illegal refining, Comrade Sheriff Mulade of the Centre for Peace and Environmental Justice painted a gloomy future of renal failures in the Niger Delta. “The situation is worse in the Niger Delta region where nobody cares. It is hard to know the prevalence and havoc wreaked by the diseases in the region and other industrial hubs,” he said.
“Incidents of kidney diseases will worsen because of weak regulatory framework and inefficiency of regulatory and security agencies in controlling activities of oil companies and illegal bunkering gangs.”
He said the toxic wastes and chemicals used by oil firms pollute the environment, and water sources, and find their way into farmlands, and fish, which are caught and eaten by inhabitants.
CKD Epidemic Raging While State, FG Are Sleeping On Duty – Nephrologists
Amidst the galloping rise in the cases of CKDs, checks conducted in about a dozen government health institutions show inadequate preparations both in manpower and facilities. For instance, Delta State, one of the biggest oil-producing states in the country, has less than 100 dialysis machines for a population of over four million Deltans. Experts said the machines are key equipment in the management of renal failures.
“The kidney plays an essential role in the human body as the organ responsible for removal of wastes, drugs and extra liquids from the body. A failed kidney is not able to perform these essentials and therefore sufferers need regular (up to thrice a week) use of dialysis machines. The frequency of use depends on the state of the patient’s kidney,” one source said.
Amidst the gaping deficiency in public healthcare, investigation also shows that private health centres charge an average of N40,000 per session; patients usually need up to three sessions weekly (N120,000/month). Justifying the charges, a technician in a private centre in Port Harcourt, said, “dialysis machines are not cheap; a brand new APD machine costs more than N7m ($10,000) and there are other costs – servicing the machine, good water source, paying personnel, electricity bill or diesel.”
•Uduaghan and beneficiary of kidney transplant at DELSUTH
Efforts to ascertain the number of centres offering the service across the states sampled proved abortive; records of dialysis treatment centres or available machines are scanty or outdated.
“Most hospitals in Nigeria do not have dialysis machines; those hospitals that do have two, three or five at the most and most times they do not work. Teaching hospitals should have up to 100 dialysis machines, but go and find out the situation. In other countries, India for instance, you see centres with 200 to 300 (dialysis) machines,” Dr Simon Tada said.
Dr. Chimezie Okwuonu, a consultant physician and nephrologist and former chairman of Abia State Chapter of NMA, had also identified the lack of dialysis facilities, and the high cost of drugs as some of the factors militating against proper management of kidney health in the country.
In Asaba, the capital of Delta State, there are just two nephrologists to nearly 1.5million residents of the north district. One of them is Dr. Akpomiemie of the Federal Medical Centre, who confirmed the huge chasm between need and help across the country. “I know of several institutions in Delta state that are looking for nephrologists,” he said.
Dr. Tada, a consultant nephrologist, said the situation is not any better in other parts of the country. He said the problem is not fully appreciated because of the lack of a database of nephrologists or their services in the country.
“I will not be telling the truth if I tell you we have the number of registered nephrologists in Nigeria. It is just recently that we started updating the registry of nephrologists in Nigeria. We do not know the number of nurses, doctors, technicians who are encompassed in the treatment.”
Our findings show that the problem is deeper than just shortage of nephrologists; ancillary services are also in short supply. Specifically, it was learnt that the number of nurses, radiologists and other technicians in the field has steadily reduced over the past year, with the extant seven-month-old strike by the Academic Staff Union of University (ASUU) across the country further decimating the rank of professionals in the health sector.
At RSUTH (former Braithwaite Memorial Hospital) in Port Harcourt, it was gathered that the flow of interns and trainees health workers has reduced drastically because of the ongoing ASUU strike. Our reporter learnt that only medical students from PAMOL (a private university in the state) are currently honing their skills at the fast-growing medical centre. A staff of the centre showed our reporter a brand new wing of the hospital, which he hinted would be dedicated to renal diseases when inaugurated.
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Dr Tada said incessant strikes critically impact quality renal health services delivery, noting that the situation would only worsen with most young people now preferring to study medicine abroad because of the uncertainty they face in public tertiary institutions in Nigeria. The normal four-year courses in government higher institutions extend up to six years because of incessant strikes by the various unions.
“Manpower shortage is a challenge, “he said. “People (medics) are running away from Nigeria – from people who are trained to those who want to be trained – they are running to other parts of the world where the education calendars are stable. Imagine lecturers have been on strike for up to seven months now. How do you discourage students who have the opportunity not to choose somewhere else? Those who want to return (after studies) would think of the situation here and what they have there. This has led to a real shortage of manpower in the health sector.”
The ongoing Russian/Ukraine war has also hit the Nigerian health sector, our findings showed. Some 4,000 Nigerian medical students were at various levels of study before the war broke out in February. Some of them are currently scattered across the eastern Europe country , preferring to brace the war than return home. Those who returned are at a crossroads over how to continue their studies. A Federal Government directive that the returnees continue their education in Nigerian schools could not be fully implemented because of the ongoing ASUU strike.
“There is no doubt that this will affect the profession,” Dr Clinton Umokoro, a Delta State-based medical doctor told this reporter. “We need a steady flow of professionals, doctors, nephrologists and other specialists into the field. There cannot be a lull because illness doesn’t take a break. When there is a strike as we regularly have, and there is a war that disrupts study in Ukraine, you can imagine how this will affect critical health manpower far beyond the present.”
MEDICAL BRAIN DRAIN: HEALTH WORKERS GO FOR GOLDEN FLEECE
The NMA recently revealed that in just two years, over 9,000 medicals left Nigeria for the United Kingdom, Canada and the USA. Dr. Innocent Ujah, NMA President, said, “available records show that between 2016 and 2018, Nigeria lost over 9,000 medical doctors. The loss left Nigeria with only 4.7 per cent of its specialists to service the healthcare needs of the most populous black nation in the world. This does not paint the country in a good light.”
As grim as the picture those figures paint, findings show that the medical brain drain has worsened since 2019 because of the coronavirus (COVID-19) pandemic. European and American countries with better packages for medics continue to dangle irresistible offers to Nigerian medical personnel, including renal diseases specialists.
Findings show that a resident doctor in Nigeria earns N200,000 – N300,000 (less than $500), while their colleagues in the USA earn 20 times more ($10,000 monthly), aside from mouthwatering bonuses that would make most professors in Nigeria envious.
Nephrologists associate President, Professor Fatiu Arogundade, in an interview with Punch’s Heathwise, said fewer than 250 nephrologists are available to 200 million Nigerians. “By WHO’s standard, we should have one nephrologist to 75-100 dialysis or transplant patients. If our population is 200 million and we assume that about 10 per cent of the population could have kidney disease that translates to about 20 million.”
All the doctors who spoke to our reporter last week agreed that the brain drain syndrome has deteriorated in the wake of economic hardship occasioned by the global economic meltdown, a tumbling naira, and worsening insecurity, particularly with kidnappers and terrorists targeting doctors, especially in northern Nigeria.
One doctor said the prospect of fleeing to practice outside Nigeria is “quite enticing” in the face of those challenges. “Even when you say there were 300 (nephrologists) yesterday, that figure could be less today. At least one person might just have taken a flight out to a ‘saner clime’. That is how serious the brain drain is now; it is scary.”
For Akpomiemie, “It takes a lot of patriotic zeal (for doctors) to remain (in Nigeria)”, adding, “It is not just about the pay – that is something we try to let the government know. You cannot pay doctors and specialists enough for the services we render. The basic thing a doctor is looking for is to get access to simple amenities and take care of our families; give them a good life, give our kids a good education and all that. Is that too much to ask for?”
KIDNEY DISEASE MANAGEMENT NUMBERS
Nigeria’s population 200m
Nigerians with kidney disease 25m
No of Nephrologists <250
Available dialysis machines N/A
Cost of dialysis (session) N35,000
Average cost of dialysis machine N7 million
Cost of kidney transplant N15 million
Teaching Hospitals that have done transplants +/-12
Doctors that have left Nigeria in 2 years >9,000
Monthly salary of a Resident doctor (Nigeria) N300,000
Monthly Salary of resident doctor (USA) N60million
He encapsulated the dilemma facing doctors thus: “Sadly, every doctor is one illness away from poverty and that’s the sad reality. If a doctor suffers a stroke today that is all. We do not have a good pension to cater for us, no guarantee of anything. It seems that after everything we put to save other lives, just one illness our world will unravel before us”, Akpomiemie said in an emotion-laden voice.
Dr. Tada said lack of professional and modern equipment and job satisfaction are among the reasons nephrologists and doctors are fleeing the country. “They are running to places with good environments and working conditions.”
He said government underestimates the anguishes of medical doctors who watch helplessly as their patients succumb to avoidable deaths due to lack of equipment. “It is painful for a doctor to watch patients die; you cannot do anything about it because there is no equipment. If you have a kidney emergency, for instance, it has to wait because it is likely that the dialysis machine has broken down and the functional one has someone who is also in a dying state using it.”
KIDNEY TRANSPLANTS: PRIVATE HOSPITALS TAKING THE LEAD
A permanent treatment for chronic kidney diseases is transplantation (replacing the sick kidney with a healthy one from a donor). Medical experts say although humans are born with two kidneys, they can survive and function effectively with just one. Members of the public are encouraged to donate to those in need, without making monetary demands. “It is unethical to make a donation based on financial inducement.”
However, our findings show that the quest for financial reward for such donors outweighs altruism, resulting in many, mostly young, Nigerians travelling to liberal Asian countries to sell theirs.
In spite of that, there has been some progress in kidney transplantation in the country. Records showed the University College Hospital (UCH) Ibadan blazed the trail in nephrology practice way back in the 1960s, but the field has expanded with the involvement of private hospitals like St Nicholas (in Lagos), which carried out its first transplant in 2000. Twenty years later (2020) the News Agency of Nigeria (NAN) reported over 700 transplants.
Multiple sources confirmed that over 1,000 transplants have been done since, yet CKD is still generally perceived as a death sentence because of the high mortality rate in Nigeria. A senior nephrologist was recently quoted as saying, “Only about one per cent of our End-Stage Renal Disease (ESRD) patients benefit from kidney transplantation.” The factor militating against rapid transplantation is the huge cost involved.
A 2020 record showed that there are about 100 government teaching hospitals in Nigeria, yet only a handful have carried out transplants. The records place Aminu Kano University as the most successful government hospital in this regard, while Lagos State University Teaching Hospital, FMC Umuahia, University of Maiduguri Teaching Hospital, OAU, Ife, and Delta State University Teaching Hospital, Abraka, have also done a few.
Uhawha and Arogundade
Government hospitals are crippled by a lack of equipment and poor funding. Most doctors said they or their colleagues had conducted emergency surgical operations/treatment relying on light from their mobile phones or hurricane lanterns because the public power supply went off before or during the operation. Where hospitals have power generators there is no diesel (fuel) to power them.
Eight years after DELSUTH performed the first in the Southsouth region in January 2014, the multibillion naira medical complex lays supine owning to paucity of funds. The incumbent governor, feanyi Okowa, a medical doctor like his predecessor, Emmanuel Uduaghan, is accused of starving it of funds. Patients in the state now travel hundreds of miles in search of renal treatments, while the governor is running to become Nigeria’s Vice President next year on the platform of the PDP. Only last Monday hundreds of protesters seized the facility to demand better, regular funding.
A PhD student of the University of Ilorin in Kwara State, who underwent a transplant at a medical centre in Abuja in July, told The Punch that he paid N15 million for the operation. But that is not the end of the story.Like any patient who gets a new kidney, he has to be on medication for the rest of his life. Doctors and analysts believe that only government’s genuine dedication to the cause can help patients.
“Without government support, transplant beneficiaries could spend the rest of their lives just trying to stay alive. All their labour and focus would be on getting needed meds, others the body defense mechanism would destroy the kidney, as it is seen as a foreign body,” one medical source said.
Apart from the costs, the problem of availability of follow-up treatments and other care is immense. Some patients travel up to 500km to get treatment, sometimes on bad roads and under constant security fears. These factors burnish the credentials of CKD as an irrevocable death sentence.
Prof. Fatiu Arogundade, who is the Registrar of the National Postgraduate College of Nigeria, tasked FG to rise up to the challenge of making CKD treatment affordable. In his address at the 34th Annual Conference in February, he advocated a National Renal Care Policy that “will standardize what is done for Nigerians with kidney disease and government’s subsidy for renal care.”
He decried a situation where most deaths from the ailment occur just weeks after diagnosis.
FEAT Foundation called for the overhauling of the health sector. “Government has to rise up to the stage as what is happening in other parts of the world. In those lands when someone is in danger they go and use the (dialysis) machine without the fear of who pays the bill. In Nigeria, even if patients are dying, it is ‘no money, no dialysis’ because the cost of the process is very expensive and nobody is ready to shoulder them.
“The hospitals in Nigeria cannot do it; it has to be done by the government. There is a need for deliberate policy, just as what was done with HIV/AIDS that has brought the epidemic down,” Dr. Toda added.