Association for Academic Surgery (AAS)

Inspiring and Developing Young Academic Surgeons

Through the Eyes of Freedom

by

The AAS Ethics Committee held its first annual Artwork and Essay Contest in 2021 – the topic for the essay contest was “What is the most challenging ethical issue, personal or professional, you have encountered in the COVID era?” The winning essay and artwork were selected by the Ethics Committee and will be published in the October issue of the Journal of Surgical Research. But we also want to share many of the powerful entries we received for this contest, so look for more of these essays to post as blog articles between now and the 2022 ASC – thank you to everyone who participated in the contest!

Krista Haines, AAS Committee Chair & JJ Jackman, AAS Executive Director

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This is the story of fifty-eight from one nation, who could very easily have been fifty–eight thousand from forty-six nations in Africa’s global south. It is told through their eyes with an understanding of their heart.

The fifty-eight of us did not have a good night’s sleep. The tossing and turning was not that induced by collective nightmares, but by excitement. Adrenaline kept the heart racing and the mind perturbed. The sweltering Lagos heat did not make it better, nor did the occasional sound of planes flying overhead out of the Murtala Muhammed Airport to the infrequent open destination. Maybe it was a poor choice booking a hotel this close to the airport. The feeling was intense and almost surreal. Tomorrow, without a visa, the agency had told us to be at the airport. A charter plane would be sent from the colonial motherland to pick us up to ‘freedom’.

The first truth was that we were all Nigerians at various levels of medical and surgical training. The nation had invested in some people’s training – or had it? Residencies were hard to come by, and the pay was cheap. You were unappreciated and underpaid. What did the future hold?

The second truth was that there was a pandemic ravaging our nation, the fires of which were only just burning higher. On top of our fair share of COVID unbelievers in favour of a biological scam and herbal healing, the daily paid labourer could not easily comply with shutting his business and his stomach down. The response across much of the nation was epileptic, with no testing capacity for kilometres. Later, in a glimmer of naive hope, we had one testing centre to about two million people at the early stages of this madness. The figures told of over 200,000 COVID-19 tests for a population of over 200 million as at the month of our exodus, and the 37,000 diagnosed (plus x undiagnosed) COVID cases were weighing heavily on a delicate health system. Whether the figures were representative were another question, but they were all we had. Though the numbers were rising in Lagos, the multicultural, cosmopolitan business capital of the nation, we were neither running from the virus nor the unearthly predictions by the West of a viral African Armageddon marked by COVID-ridden bodies riddling the streets. We were running from the push of uncertainty- poor working conditions, comparatively low pay, lack of opportunities, the literal power ‘holding’ companies, and yes, this heat.

The truth was also that there was an ethical tension in most of the fifty-eight beating hearts. A secret yearning that things would get better on this side of the Atlantic so we would not have to run for cover. A hope that we would not need to join the 8,000 Nigerian doctors already servicing another country’s health system, while ours tottered on a deadly precipice.

The British visa office in Nigeria had been shut for months, and there were no United Kingdom bound commercial flights in or out of Nigeria. A few weeks earlier, at the peak of the decimation of the COVID virus on both frail and supposedly strong health systems, the British government suddenly relaxed its visa requirements for medical personnel. It was an ace tagged ‘Health and Care Visa’. It seemed to be a matter of need, but the tension appeared more a matter of poaching from the poor to save the rich. Emigration was being made easier to solve a local part of a global problem, sometimes to the detriment of other weak health systems steeped in the same global problem. What was difficult before had become easy.

Three weeks earlier, the potentials had received a letter from a healthcare recruitment director. The essential messages were ‘Be at the airport on the 10th of July. Contribute 500 pounds sterling to your heavily subsidised charter flight ticket. The UK Visa and immigration office has waived your visa till you arrive here because of the situation of office closures.’  The accompaniment was almost flattering as several diplomatic hoops disappeared. Was this a ‘reverse Robinhood’ situation of stealing from the poor to give to the rich? What other choice did the United Kingdom have at a time when thousands of lives were being lost by the day, and the last stand would only be possible by the help of anyone, from anywhere? The European conscience was pacified in not dictating where the doctors would come from. That they come from a country with a doctor to patient ratio of 1 to 4000 to a country with 12 doctors for every 4000 was not a matter of conscience. Or was it?

UK-bound flight number ENT 550 with registration number SP-ES was available, but for the fifty-eight, the next day went by in a blur. The Nigeria Immigration service for some reason stopped the departure at the Murtala Muhammed International Airport. They were not aware, they said, of any arrangement for departure without visas from Nigeria aboard a charter plane. There was a roller coaster of emotions that day- the type that might accompany a foiled jail break of innocent prisoners to the captivity of a virus and a nation.

But when it is High-Income versus Low-and-Middle-Income-Country, it is better to be on the winning side. Do not ask me which team won with the fifty-eight. I have the right to live anywhere, but how ethical is my being poached, amid a pandemic, from a country that has trained me and needs me, but is overtly or covertly pushing me away? I have the right to live anywhere; but do I have the conscience to live anywhere?

A short while later, after a short road trip to a neighbouring West African airport, the fifty-eight joined the 8000- set free by a virus that not only steals life, but steals physicians- surgeons, obstetricians, anesthetists, and non-specialists from where they are most needed to where they are most paid.

 

But what is truth?

Barnabas Alayande

Barnabas Alayande

A General Surgeon with the Nigerian National Postgraduate Medical College and a Senior Registrar with the West African College of Surgeons, Barnabas was trained in the LMIC context and has Global Surgery interests. He has trained in a WHO Collaborating Centre, has a background in theology and is a Paul Farmer Global Surgery Fellow with the Program in Global Surgery and Social Change, Harvard Medical School and Boston Children's Hospital, MA. He is also a Global Surgery fellow with the University of Global Health Equity, Rwanda and volunteers with the Faith Alive Foundation, Nigeria. His research interests are in LMIC surgical education, Non Technical Skills for Surgery in Variable Resource Contexts, surgical improvisation and innovation for the LMIC context, and health resource management.
Abebe Bekele, MD FCS FACS

Abebe Bekele, MD FCS FACS

Abebe Bekele, MD, FCS, FACS is Deputy Vice Chancellor of academic and research affairs and Dean of the school of medicine at University of Global Health Equity in Rwanda, and is actively engaged in global safe surgery and anesthesia initiatives. He is a professor of surgery with positions at the Addis Ababa University and the University of Rwanda, and is chairman of the Examinations and Credentials Committee at the College of Surgeons of East Central and Southern Africa. He has vast experience in trainee assessment, program design, and evaluation and served as a senior advisor to Ethiopia’s Federal Ministry of Health in the Saving Lives Through Safe Surgery initiative. He is also a member of the advisory council to the Ethiopian ministry of sciences and higher education. Twitter: @abebesurg
Abebe Bekele, MD FCS FACS

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Robert Riviello, MD MPH

Robert Riviello, MD MPH

Robert Riviello, MD, MPH, is an associate professor of Surgery and of Global Health and Social Medicine at Harvard Medical School and a Trauma, Burn, and Critical Care surgeon at the Brigham. He is head of the department of surgery at the University of Global health Equity, Rwanda, and Director of Global Surgery Programs at the Centre for Surgery and Public Health, and has dedicated his career to improving surgical access for vulnerable people. Over the past decade he has split his time between BWH and sub-Saharan Africa, strengthening surgical systems, training programs, and providing mentorship to several global surgery fellows. Twitter: @robertriviello
Robert Riviello, MD MPH

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About Barnabas Alayande

A General Surgeon with the Nigerian National Postgraduate Medical College and a Senior Registrar with the West African College of Surgeons, Barnabas was trained in the LMIC context and has Global Surgery interests. He has trained in a WHO Collaborating Centre, has a background in theology and is a Paul Farmer Global Surgery Fellow with the Program in Global Surgery and Social Change, Harvard Medical School and Boston Children’s Hospital, MA. He is also a Global Surgery fellow with the University of Global Health Equity, Rwanda and volunteers with the Faith Alive Foundation, Nigeria. His research interests are in LMIC surgical education, Non Technical Skills for Surgery in Variable Resource Contexts, surgical improvisation and innovation for the LMIC context, and health resource management.