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Under-reported gynaecological problems - | - Plight of cancer patients


  • Under-reported gynaecological problems
  • Plight of cancer patients


Under-reported gynaecological problems
Written by Dr. Sylvester Ikhisemojie

~Punch, Nigeria. Sunday, May 22, 2016
Dr. Sylvester Ikhisemojie
The spectre of having to deal with specific problems such as vesico-vaginal fistula and recto-
vaginal fistula are important conditions which many people across the country have become familiar with. Not the least because of the stigmatisation associated with those conditions and the campaigns that has helped to bring attention to the abnormal situation.

These problems are known to be associated with largely unsupervised deliveries in the rural areas, just likeutero-vaginal prolapse, also known as UV Prolapse. This is a condition that is associated with unsupervised delivery invery young expectant mothers who are commonly in their teens. Expectedly, this problem is seen mostly in the underdeveloped Third World where ignorance, disease and poverty hold sway.

Utero-vaginal prolapse is an abnormal condition where parts of the female genital organs descend into the vagina and the person becomes aware of that anomaly. The level of descent varies in accordance with the severity of the weakness in the supporting structures that hold the uterus in place. Sometimes, a part of the uterus may descend into the vagina; that is usually the cervix, the neck of the womb, which the woman is able to feel. At other times, the entire uterus may descend into the vagina. Worse still, the spectre of the entire uterus actually passing through the vagina could be turned completely outside. If it is as bad as this, then the situation is desperate, with the patient constantly aware of the fact that she is undergoingan abnormality. The organ, now inside out, is prone to bruising and ulcer-formation. As a result, there is associated bleeding,constant infection and the woman descends into poor health. Through it all, she is largely left to her fate. It is cruel.

Many of these conditions are common in many parts of Nigeria where forced under-age marriages occur. It is perhaps far more common than the much more popular conditions like VVF and RVF. The causes are similar. Many victims are themselves children who are forced to have babies at the time they develop the condition.
They are the lucky ones to begin with, being that they are the ones who have endured prolonged labour stretching into several days in the homes of the village medicine man but often also, in the homes of their mothers. There is little or no form of hospital care and no ante-natal services of any kind were obtained along the way to the delivery date. Many die in the process, but these ones have at least, survived the ordeal. It is thus a vicious cycle of underage pregnancy in an individual who endures prolonged labour with little or no midwifery supervision.

Some of these people ought to have Caesarian sections either on an emergency basis or electively as provided for during the ante-natal period. As they have had no form of exposure to modern midwifery services, they are doomed from the start to end up with some form of problem or the other. This is a sad sign-post of the level of our under-development.The very fact that there are no national statistics to properly determine the very scale of the problem and the burden it represents is a national embarrassment. Around the nation, many health related projects are sited at the whim of some politician or local lord who holds some influence within the scheme of things. Mostly, there are no statistics available to guide any such efforts and large swathes of territory that could harbour many millions of people are simply neglected because they were not captured in the relevant data or do not have the appropriate representation. As a result, there are communities within our country today that are a full two days away from the nearest hospital to them. Such places have no roads. Where the roads are available, there is no reliable transportation other than by motorcycle or donkey, not to mention riding on the backs of several relatives. As a result, any of the problems documented above can result.

Utero-vaginal prolapse comes in different stages of severity. These are variously divided into four stages which are nice to know from the position of a classroom. What is of concern to any reader here is that whatever the stage, an operation is required to correct the problem which is aimed at strenghtening the weakness in the pelvic floor muscles brought about by so much suffering in the course of childbirth. There are also some related conditions that will require operative correction as well and these are cystocoeles and rectocoeles. Identifying what the problems are in any patient is the easy part.

The long-term solution can only be provided by a trained gynaecologist of which there are only a few considering the size of the problem. Worse is the fact that many of these gynaecologists are based in urban areas to whom virtually all of the victims have no access.

The patients are in a no-win situation. They had poor care or none at all while pregnant. They fared worse in the course of a difficult labour and emerged from the process with some structural damage to their internal organs. When they have vesico-vaginal fistula, they continuously drain urine and smell always. When they have the rectal variant, they leak faeces with similar results. When they have the utero-vaginal prolapse, they are unable to perform their social, conjugal functions. In every situation, their prospects are dire; they are often ostracised, abandoned and left to their fate. Sadly, this today is the lot of the rural, underaged woman who gets pregnant and is forced by circumstances around her to deliver with no form of medical supervision at her service.
Plight of cancer patients
Written by Dr. Sylvester Ikhisemojie
~Punch, Nigeria. Sunday, May 22, 2016

Dr. Sylvester Ikhisemojie
Many years ago in Nigeria, people with certain kinds of ailments were assured of prompt and affordable treatment provided in some of the best hospitals anywhere directed or monitored by skilled men and women. Today, those skilled men and women still exist but the facilities available have steadily fallen behind what is available in the rest of the world.

In those far gone years, people who suffered from tuberculosis, leprosy or cancer were afforded free treatment in any hospital where they were presented for diagnosis and management. We have seen how even the availability of medications has become an issue in the past two decades. Worse still, is the fact that some of the drugs presented to victims of those conditions on behalf of a sympathetic humanity found their way into Idumota and Onitsha markets, and were made available for sale to those who had the wherewithal to purchase the drugs at a discount.

In the past several weeks, reports have emerged about how money available to certain Nigerian organisations charged with the provision of health support services disappeared into private bank accounts. The result? Many beneficiaries are denied their entitlement in favour of a few predators who want to live beyond even their dreams. Evidently, we do not even show love to our fellow citizens. But all that is a digression; the major plank of this essay remains that we lost focus along the way and essentially left the confused citizen alone to fend for themselves and feel their way around very unfamiliar territory.

The typical story goes like this; someone with a suspicious problem first visits a chemist or a health personnel in the neighbourhood. They get a prescription for some medication. Sometimes, the prescription is for a herbal mixture. After several weeks, there is no improvement and the person then visits a proper hospital.

Once at the hospital, he gets to see a doctor who examines the patient and recommends a battery of tests. These tests are conducted over several more weeks before they get another appointment even to have a biopsy taken. The confirmatory result takes a while to return its verdict. That could take anywhere from 10 days to three weeks or more. In the meantime, if the original growth is a cancer, it has continued to increase in size and complexity.

Now then, there is a diagnosis and what remains is what to do about it. All the counselling is done and surgery scheduled. If there is no industrial action involving any of the various health care providers, the operation goes ahead as planned and the growth successfully removed.

After several more days or weeks, the wound heals and the patient gets to be referred to another medical facility that can handle the next phase of the treatment. Such a hospital may be many kilometres away and could even take an entire day of travel time. Now, by the time chemotherapy is concluded, the radiotherapy machine, if there is one, would have stopped functioning mostly due to old age and over usage. The patient is then forced either to wait for the machine to be repaired, which may take their lifetime or go to yet another hospital.

Sometime in 2014, there was a particularly desperate time for many cancer victims in the Southwest of Nigeria. The radiotherapy machine at the Lagos University Teaching Hospital, LUTH, had broken down. A similar fate had befallen the machine at the University College Hospital, UCH, Ibadan.

In an entire land area, a quarter the size of the federation, only the machine at EKO hospital in Lagos was available to provide that service for so many people. The scenes of desperation are better imagined. Many hapless patients who were unable to afford that private service simply passed on early. Others were more fortunate for they then found their way to Enugu, at the University of Nigeria, Teaching Hospital. However, it is obvious that this kind of tortuous movement in pursuit of affordable health care cannot be sustained. Nor should that be the fate of hundreds of thousands of men, women and children who are stricken with this terrible disease.

As the nation's population has increased, so has the number of cancer patients. There are a lot of hospitals now across the country and many adequately trained health care professionals. However, there are a lot of gaps in the system, the referral system is faulty and inadequate. Often, practitioners are not sure where to send their patients to because what held true yesterday may have altered today almost beyond recognition.

A doctor who has examined a patient reaches a diagnosis but that is not confirmed until he has a biopsy result in hand. What these people need most of all, therefore, is not sloganeering at the various campaign events or choreographed press conferences. It is a concerted effort to strengthen the infrastructure already available rather than seeking to build entirely new structures that now essentially stand alone somewhere like some orphan edifice. The reason for that is clear.

The fact that a new complex has been built somewhere may look really good politically or even in the eyes of the public. It is wrong, however, to assume that a specialist centre can evolve around such a facility. What is more practical is to situate such a specialist centre within a hospital that has its own native manpower already in place and is simply available to seamlessly absorb the new addition. That is organic growth and it is the way it has been developed in other lands. Nigeria cannot grow its health care system by doing it the other way. That would be much like driving from Abuja to Kano, using the reverse gear when you might as well go forward in a way that does not add to your physical discomfort.

What good can result from building a cancer diagnostic centre in Zungeru, because one prominent son of the town died of cancer of the throat? Why not place it within a specialist hospital in Minna which already has some personnel to whom more hands can be added? The new centre in the meantime is a full-fledged hospital in all but name. It would have its own regular doctors who will primarily attend to patients. It should also have wards for admission and treatment and even to conduct certain investigations. It must have modern imaging devices­—ultrasound machines, digital X-rays, CT scans, MRI scans, fluoroscopy, angiography equipment and all of them with their full complement of staff.

Then there should be a department of radiotherapy which is different from the above in terms of staff and equipment and complete with radio-isotope facilities, able to conduct radionuclear scans and isotope studies. And then a laboratory with every specialty in place (morbid anatomy, clinical chemistry, haematology and medical microbiology), including histopathology and histochemistry. There should then be another department of nuclear medicine, a large field recognised even by some other Third World countries such as Iran and Cuba. Of course, there must be operating rooms also with their staff complement. If these are not in one place, you do not have an integrated cancer treatment centre.

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