Eruwa — Dr. Oluyombo Awojobi, the Secretary of the International Federation of Rural Surgery, has practised rural surgery for over 30 years. His style, our reporter discovered on a recent visit there, is the reason treatment is affordable, efficient and therefore attracts people from across Nigeria and beyond.
Eruwa town, Oyo State, about an hour's drive from the state capital, Ibadan, could be described as the hub of medical tourism in the area. This is not because Eruwa is home to a district hospital built in 1970 which later became the Eruwa General Hospital. It is a destination for patients and academics from the global health and development community as well as foreign journalists because of the Awojobi Clinic Eruwa (ACE).

It is not only pregnant women you can expect to see here: there are pregnant goats lying on their sides in the early morning sun, so comfortable that they reluctantly move aside for cars and motorbikes to drive through. Hens and cocks cluck loudly beneath trees heavy with cashew fruits; a welcome of sorts for visitors to ACE.

The first sight which greets the eyes at the clinic's entrance is the 'Keke Eruwa' an improvised ambulance made from discarded motorcycle parts and metal scraps, which serves as an ambulance. Looking up ahead, lamps made from empty medicine kegs and old rubber saucers which hold miniature light bulbs in place, dangle from the ceiling and give light to the records unit beneath them.

Then there is the car jack, which is used to lift up and lower beds as needed when surgery is being carried out on patients. Waiting to be attended to is a crowd of patients and their relatives, some of them lying on the benches as women walk back and forth with babies strapped on their backs offering words of comfort and encouragement. They all warmly greet and appreciate Doctor Awojobi as he inquires about their wellbeing. According to the Association of Rural Surgical Practitioners of Nigeria (ARSPON), 'Rural' in this context does not necessarily refer to geographical location alone; it refers also to inadequacy of equipment, infrastructure, conditions of work, environment and even knowledge. It is the aim of ARSPON to rectify all these.

In line with these objectives, Awojobi has proved that they can be rectified with very little efforts and from resources readily available which cost little or nothing.

While enhancing and improving upon the quality and standard of rural surgical practices in Eruwa, Awojobi uses old bicycle pedals, corn cobs, carcasses of machines among other materials he gets from his 'backyard'.

Practical and functional, not fancy or aesthetic, were Dr. Awojobi's watchwords when he started the clinic in 1983. He has achieved this by running his hospital on very low-tech innovation unique to him, using recycled trash and discarded materials from his immediate environment.

Though evidently well in use, the operating room is well-equipped with tables, surgical lamps, aprons, oxygen cylinders, proper ventilation, sterilised normal saline and cotton gauze, among other essential items.

Its most antique and still reliable furniture is the car jack-motored operating table described earlier. This and the autoclave were Awojobi's first creations in 1985 when doctors in Nigeria were threatened with mass sack. "I said if that happened to me and I had to go into private practice, the things I needed as a surgeon were the operating table and autoclave. These cost "an arm and a leg. Buying them would mean my services won't be available to the common people who constitute the majority. I studied the imported autoclave and its components. I was able to use the ordinary gas cylinder to make one.

"For the operating table, having studied the imported one made of cast iron, I was able to design a prototype using all wood and it worked, but because the wood couldn't take so much weight, I converted the essential parts to metal."

The clinic's first operating table was 90 per cent wood and 10 per cent metal. It has been in use since 1986 with only the two pieces of wood on which the table rests, changed to bigger ones. "The formica is a bit torn, but I still use it, because it's functional and for historical purpose," said Awojobi.

Illuminating this operating room is a surgical lamp made from energy saving bulbs shielded by a N250 aluminium bowl. The exact type of bowl used by food vendors on Nigeria's streets from Lagos for steaming bowls of meat, to Maiduguri, where this same bowl Awojobi is using to help save lives holds 'fura', a millet-based cereal.

Eruwa community lacked power supply from the national grid for six years from 1993 to 1999. With centrifuges being expensive and needing electricity to work, Awojobi again put on his thinking cap.

"The centrifuge is equipment which tells how much blood a patient has and therefore how much he might need. I needed a speed of about 3, 600 revolutions per minute to be able to get my results."

Made from discarded bicycle, Awojobi's manually operated haematocrit centrifuge revolves at 5, 400 rpm and can be used by patients' relatives if laboratory staff are busy. "This way, relatives also monitor and can manage patients. This is an important part of rural surgical practice which I learnt on arriving Eruwa," he said.

The centrifuge is made up of two old bicycle wheels, somewhat similar to Britain's penny-farthing bicycles of the 18th century. The wheels are rotated by hand and the speed with which the wheels rotate to mix up a collection of blood samples in tubes, separating the cells for further analysis.

An added plus for Eruwa, being a predominantly farming community, is that farmers are glad to dump their corn cobs at ACE for stipends with a bag selling for just N80 against N1,400 for a bag of charcoal that provides the same amount of energy. These cobs are fed into a furnace by shovel to fuel the hospital's sterilising unit and distiller, through the production of steam. For alternative energy sources, the clinic has solar panels strategically positioned around its structures, which provides backup electricity.

To ensure that the hospital never lacks water, the clinic has its own water supply which Awojobi, a University College Hospital, Ibadan graduate, constructed from the community's seasonal stream. Water from the dam is fed into a boiler and then the autoclaves before going into a second boiler which produces distilled water which is used for normal saline (intravenous solution) production.

The normal saline is then bottled sealed and sterilised and stored for its forty eight-hour shelf life.

Rain water is also collected from the roof tops and stored in tanks around the clinic through the network of pipes strategically channelled.

All around the premises there are pieces of recycled materials which now serve the clinic efficiently. They include a pair of washing machines fabricated from parts of condemned washing machines, as well as a lawnmower still in construction amongst other items.

With the inventions exclusive to him, maintenance and repairs are easy. "I sketch my designs and take them to welders and workmen around who build them. Therefore, maintenance and repairs are easy."

Inspired by Biafra

On how he came about his creations, Awojobi said it was shortly after the civil war. "I was on my way to visit my elder sister who was a nurse in Okitipupa General Hospital, and a few kilometres from Ore I saw an abandoned contraption. I asked the driver to stop and went to examine it. I found it was a Biafran Red Devil made from a Land Rover, plated with armour and converted into a battle tank. So, I said to myself, if fellow Nigerians could produce such, even if it were for a destructive purpose, it meant that if we geared our energy to something more productive then our country could move ahead.

"In a way that was inspiration for me, to use what we have to get what we need. I told myself that if the Biafrans could do such, I could do much more to resolve Nigeria's health crisis," he said.

Born into a family of engineers and being the youngest of the Awojobi brothers, the then eight year-old decided, he would be different and read medicine instead.

After 11 failed attempts to be employed by the Ogun State government as a consultant surgeon, in 1983, he was employed by Oyo State government and posted to District Hospital, Eruwa. He described this as coming back home as he was in Eruwa in 1974 as a medical student and in April 1980 as a trainee surgeon.

The low cost and easy availability of materials make treatment cost very affordable as patients testify.

Solanke, a patient from Lagos who recently had surgery for fibroid and was recuperating, said she was directed to Eruwa by a staff of the hospital where she was previously being treated. "When I was diagnosed with fibroid, the initial cost I was told was N160,000. By the time my husband and I put the money together and went back to the doctor, we were told it had increased to N180,000.

"Coming here, I paid only N90, 000. Dr. Awojobi is who I'll describe as a man of the people. He has truly lived out the ethics of his profession which is saving life first. It was only the day after the surgery and he knew I had spoken to my family and was feeling better that he asked me to go and pay."

Another patient Folake was happy to have been charged only N25,000 as against the N75,000 she had been asked to pay at one of Lagos' government hospitals.

"It's not only us from Nigeria who come here. We even met a patient here from Cote d'Ivoire," Folake added. Saliu Abdullahi, a patient who came from Lagos after being on different treatment courses which made no improvement on his condition, said he was advised that surgery was the only way out and at N500,000 at the Igando General Hospital. "It isn't that Lagos doesn't have hospitals, but they are too expensive and you are not guaranteed the quality of doctors who attend to you. Even with your money, there is no assurance that you will be treated properly.

"Here, you are sure that even if the doctor doesn't carry out the surgery himself, he will be there to oversee things and this makes all the difference. So far, I've spent N90,000." For Dr. Awojobi, "it's about making things affordable to patients at one tenth of the amount they would ordinarily get it in the open market. That's why we produce our own normal saline which costs us N20 as against N200 in the open market." As part of quality control measures, once it expires, "any unused fluid after these 48 hours is converted to cleaning wounds before dressing," he said.

With only two qualified nurses on his staff, Awojobi meets the high demand for healthcare by employing Community Health Extension Workers (CHEWs) a scheme initiated by Prof. Olikoye Ransome-Kuti created while he was Minister of health.

Every now and again Awojobi admits that he has to deal with herbal medicine practitioners and their hold on patients.

"Many cases that come to me are already very terribly treated and gone worse than if they were immediately brought here. The so-called herbalists also make use of orthodox medicine as part of their treatment regimes. Also, I do not blame the patients for going to the herbalists, because orthodox hospitals are in many cases not patient-friendly," he said with a frown.

One of Awojobi's greatest joys would be to see other hospitals replicate his works to improve healthcare delivery. So far only 8 hospitals in Nigeria's South West have, though, "I don't have patents to any of them because I would like them to be replicated as much as possible. My presentations and publications of them are more than enough patent for me," the doctor said.

His inventions have won awards including the Natural Agency for Science and Engineering Infrastructure (1992) which he received for his distiller; Marquis Who's Who Biographee in Science and Engineering (2003) and a Meritorious Award in Medical Engineering and Practice (2009) among others. He has also presented papers on 'Future Health Systems: Innovations on Marketing Health Systems Workshop' (Nigeria) and 'Appropriate Technology in Rural Surgical Practice: The Nigerian Experience' (Greece) among others presented in Thailand, London and other countries.

Awojobi deliberately received all his training in Nigeria and sojourned abroad for the first time in 1995; 20 years after becoming a doctor and 12 years after becoming a surgeon.

In an effort to transfer his knowledge as well as provide training opportunities for younger doctors to acquire surgical skills, Awojobi who firmly believes in Nigeria and the fact that good things come out of here, is training young doctors who are drawn to the rural community to satisfy their hunger to be expert rural surgeons rather than be lost amongst the multitudes in urban practice.
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