Visiting medical students and residents gathered with Tanzanian registrars at Dr. Swanson's home

Ejiro Orubu, M.B.B.S. PL2, Nigeria, January 10 - February 6, 2022

My global health rotation is an ongoing comparative effectiveness study evaluating the safety of methylated spirit for cord care in newborns with glucose-6-phosphate-dehydrogenase deficiency (G6PDD). We intend to compare the incidence of neonatal jaundice in G6PD deficient neonates whose cord care was performed with methylated spirit or other substances with the incidence in a similar population who used chlorhexidine solution for cord care cleaning. The Lagos University Teaching Hospital (LUTH) was selected as research site for this project. LUTH is a tertiary healthcare institution in Lagos State Nigeria with a pediatrics department that has two neonatal intensive care units. One intensive care unit serves babies delivered in the hospital who have known maternal/childbirth history, while the other serves neonatal emergencies from the surrounding community. LUTH is a resource-constrained institution with limited experience in performing clinical or health outcomes’ research. It however has leadership and organizational structures in place that could make it as an excellent site for healthcare research collaborations. The hospital would benefit from knowledge transfers from better resourced institutions that can demonstrate serious commitment to rigorous and high value work.

I am Nigerian and spent my growing years in Nigeria, and so I am very familiar with various cultural interactions and how they influence patient care. However, during this project I was perceived as a foreigner; and so in our many interactions with the LUTH team, I was the ‘insider without’. I observed how American ethnocentrism influenced our interactions with our Nigerian counterparts. Although our role was research focused, we were invited to participate in ward rounds and in discussions on some patient care. This suggested a power imbalance between our hosts and ourselves. I suspect that if the tables were turned and they were guests at our hospitals, their roles would be limited to observation with restricted contribution to individual patients’ discussions. While we clearly did not impose ourselves on the pediatric team we worked with, these interactions reveal the work that needs to be done by both sides of the global health hemisphere to decolonize global health.

I grew up in Nigeria and returning home is always a pleasure! The culture and societal organization are starkly different from what we have in the US but visiting Nigeria in whatever capacity is always a very welcome departure from what obtains in the US. People in Nigeria tend to be friendlier and more open. Resource constraints and poverty tend to make interactions quite transactional, but the informality, immersion in a collectivist culture and fantastic weather make being in Nigeria a great short-term trade-off. My main concern in Nigeria was the likelihood of catching Covid-19 or malaria while in the country and not being able to reunite with my family. I took adequate prevention measures – masks, PPE (where available), mosquito repellents, multiple testing, and social distancing.

Medical research governance and oversight in LUTH was poor. While we ensured we adhered to strictly and  complied with Good Clinical Processes (GCP) standards, such practice did not appear to be prioritized in LUTH. This of course can create situations where bad actors can take advantage of the lack of systems for ethical research. Perhaps an area of future collaboration would be a collaboration to institutionalize a governance system for medical research in LUTH.

I do not recall any one situation where I reserved a judgement of the medical system in LUTH or of Nigerian politics. Nigeria is a developing country with a lot of cultural and political challenges. However, global events of the past five to six years have shown that every country is facing very serious cultural, political, and even socio-economic problems. In the final analysis, it appears we are all facing the same problems. No challenges are especially unique to any country. The difference is merely in the degree to which these problems are prevalent.

My experience in Nigeria showed me the need for governance structures in improving global health systems. Stateside, we view our healthcare system from clinical and administrative buckets. In international/global health, there is a need to further disaggregate these using the WHO categorization of healthcare systems – governance, financing, human resources, health technology, information systems and service delivery. Research collaborations that do not focus on identifying gaps in all these buckets will be inefficient and may lack internal validity, despite excellent clinical skills being brought by international partners. Our research partnerships should be multi-pronged, focusing on upstream – governance, health system coordination; as well as downstream activities -  service delivery/research activities.

I would like to contribute to the organization of research collaborations with healthcare facilities and systems in resource constrained settings. As I described above, focusing on various building blocks of the health system from a research perspective will help us better achieve our goal of knowledge transfer, and would make our interactions less extractive than they currently are.