Providing Intensive Care for Children in Nigeria
When Dr. Odiraa Nwankwor embarked on a career as a pediatrician, he never imagined the ripple effect his career choice would later have in his home country of Nigeria. Little did he know that he would eventually improve the health of countless Nigerian children in a lasting and substantial way: by creating, funding, and training the staff at Nigeria's first Pediatric Intensive Care Unit (PICU).
Nigeria is the most populated country in Africa, with just over 200 million residents. But surprisingly, there are no PICUs in the country. Realizing that children weren't getting the care they so desperately needed, Dr. Nwankwor knew he had to help. "This is a very big moral burden," he said. He wanted to "change the trajectory" of pediatric healthcare in Nigeria.
Nigeria does not have the same healthcare resources as the U.S. Instead, children with severe injuries or illnesses are cared for in the same setting and with the same resources as less critically ill children. However, due to Dr. Nwankwor's persistence, dedication, and creative grassroots efforts, this model of care may become a thing of the past, as one Nigerian hospital prepares to open its first PICU.
How It Began
Dr. Nwankwor has had a passion for global health throughout his career. He attended medical school at the University of Nigeria - Enugu Campus and then completed his Masters in Public Health (MPH) at the University of Lagos and worked as a general practitioner in Nigeria.
Following this, he moved to Dublin, Ireland, to work as a Senior House Office in Emergency Medicine. He then completed his pediatric residency at the Woodhull Medical and Mental Health Center in Brooklyn, NY, a program of New York University. It was after this that he began working at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Deleware.
In 2011, he received a second MPH from the Bloomberg School of Public Health at Johns Hopkins University. While there, he met a number of students with similar interets in humanitarian care, and these connections would play an important part in his future work.
After receiving permanent residency status (a "green card") in the U.S. in 2012, Dr. Nwankwor went on to complete a Pediatric Critical Care fellowship at the University of Maryland before returning to Nemours/Alfred I. duPont Hospital for Children, where he is now a member of the teaching faculty.
As he settled into his new career and reconsidered his dream of bringing pediatric critical care to Nigeria, Dr. Nwankwor knew that he had the ideas, passion, training, and understanding of his country's medical system to get a program off the ground. But what he didn't have was the equipment, money, or team of trained professionals. After careful consideration, he used his knowledge of the local healthcare system and culture in Nigeria to dictate the next steps in making his dream a reality.
Why Critical Care Is Critical
The infrastructure and funding of Nigeria's healthcare system differ in many ways from the U.S., where Dr. Nwankwor has been practicing for the last 16 years. Nigeria spends about 3.8% of its GDP on healthcare, compared to 17.7% in the U.S. Despite signing on to the Abuja Declaration with other African nations in 2001 and committing to increasing healthcare allocations to at least 15% of the annual budget, Nigeria, as with most of the signing countries, has not reached this target.
To date, much of the humanitarian effort related to child health in Nigeria has focused on primary prevention. This makes sense, as initiatives like mass vaccination campaigns can have a considerable effect on decreasing childhood mortality. These primary prevention efforts are vital, but they do not address all child healthcare needs and should be viewed more as a starting point than a finish line. Even children who receive ideal primary preventive care in the form of vaccines, well-child care, and nutrition can still require critical care later in childhood as a result of unpreventable asthma, diabetes, or trauma.
Supply, Personnel, Support, Space (SPSS)
The long road to project completion began with an interesting first step. Before even having space or personnel in Nigeria, Dr. Nwankwor began asking his colleagues in the U.S. how to obtain the necessary PICU equipment. He spoke with his department chair, Dr. Meg Frizzola, and Nemours Global Health Services Medical Director Dr. Chris Raab. Through them he learned of a grant offered by Nemours, which he applied for and was awarded. The $27,050 eventually funded travel costs for U.S. healthcare workers to travel to Nigeria to set up the unit and train local staff.
Next, he connected with Joel Brown of respiratory services at A.I. duPont Hospital for Children and asked if there was any unused equipment in storage the hospital would be willing to give him. With that request, Dr. Nwankwor gained a reputation everywhere he went as a "treasurer hunter" for gently-used medical equipment. This task would come to occupy much of his free time over the next 3 years.
Dr. Mike Goodman at Cooper University Hospital, where Dr. Nwankwor is also on staff, connected him with employees who were also able to donate supplies. Dr. Nick Slamon led him to PromptCare, a respiratory care company, that donated LTV ventilators, blood pressure measuring equipment, and feeding tubes -- donations worth more than $40,000. Eventually a connection was made with the General Electric company, which donated four cardiac monitors. Suddenly, the Health Place for Children Initiative was on its way.
It may seem unusual that Dr. Nwankwor set about collecting equipment before he even had a place to house his PICU or a staff to run it, but he knew from the beginning this was the best way to approach the project. He understood that people would need to see that a PICU could be a reality in Nigeria before he could get any local buy-in.
Dr. Nwankwor explained that the classic approach for these types of projects in resource-constrained areas is to first enlist staff, but his variation from this widely-accepted mantra proves that one size does not fit all. Instead, he advocates for a model he has since termed SPSS (supply, personnel, support, space). These are the four elements that are essential for this type of project and he believes that project leaders should pursue them in the order that best suits the individual needs of a community and its organizers.
As generous donations began flowing in throughout 2016, Dr. Nwankwor had to rent a storage locker in Cherry Hill, New Jersey to house them all. Volunteers came to box up the supplies, and he used crowd-sourced funding to pay for shipping to Nigeria.
Meanwhile, Dr. Nwankwor reached out to a medical school classmate in Nigeria who is now the chief medical director of the hospital where they trained. Because of their personal connection and trusting relationship, Dr. Obinna Onodugo was more than happy to support all aspects of the project. "He knew if I said I was going to do something that I was going to do it," Dr. Nwankwor said. Down to the smallest details, Dr. Onodugo and his colleague, Professor Tagbo Oguonu, came through. "I told him I wanted the windows changed so that dust would not be coming in. I also told him I wanted to pipe in oxygen, air, and suction through the wall. He did every single thing that I asked him to do."
Perhaps the most important part of building this partnership in Nigeria is Dr. Nwankwor's philosophy that "we are doing this with them and not for them." Every step he takes toward the finished project is designed to empower the local community to take charge of the project and prepare to lead it themselves.
Bringing It All Together
In 2019, after years of planning and fundraising, Dr. Nwankwor was finally ready to take a team from the U.S. to Nigeria to set up the PICU space and train the local staff. His team consisted of one surgeon, three pediatric intensivists, two respiratory therapists, and four nurses. They transformed the space and provided education on the use of new equipment for monitoring and care.
There is a crucial concept about the nature of pediatric critical care that Dr. Nwankwor wants to instill in both the staff at the University of Nigeria Teaching Hospital and those in other resource-constrained areas currently lacking a PICU: pediatric critical care often does not require substantial equipment and intervention. He wants to create a "paradigm shift" in how pediatric critical care is viewed. For instance, he has pointed out that up to 80% of pediatric patients in an ICU setting do not require a breathing tube and ventilator. More often, patients require more intensive monitoring and clinical vigilance than is typically provided on a standard pediatric unit.
Unfortunately, shortly after Dr. Nwankwor and his team visited the new PICU and brought it one step closer to opening its doors, the COVID-19 pandemic swept across the world and created an unanticipated delay in their ability to finally provide patient care. Now that the pandemic is showing signs of subsiding and the worry that their equipment might be needed to provide care to COVID-19 patients is passing, they have decided to start admitting their first patients in the near future.
Becoming A Local Model
Although it may seem that Dr. Nwankwor's work is done now that the local staff are prepared to begin providing care to critically ill children, he instead views this as the completion of the first step in a much longer journey. Nigeria has six geopolitical regions, and his dream for the country is to have a PICU in each of these regions by 2025. By starting with the region and hospital with which he is most familiar, Dr. Nwankwor aimed to create the most successful model possible to inspire other regions and healthcare workers. This provides the "proof of concept" that he knows is essential to build interest and enthusiasm for a new program.
With the dream of growing bigger and better comes the need to continue to train personnel and keep them up to date in the specialty of pediatric critical care medicine. There are currently two programs in Africa that train pediatricians to be pediatric intensivists, located in South Africa and Kenya. By arranging for Nigerian physicians to train at these programs, Dr. Nwankwor has created a pipeline for continued professional development and staffing for current and future Nigerian PICUs.
The growing opportunities for telemedicine and remote learning for staff further enhance future capabilities and learning capacity for the new PICU. Additionally, native Nigerian colleagues in the U.S. who practice other pediatric specialties that do not currently have a presence in the region have approached Dr. Nwankwor with an interest in following his lead to establish their specialties in the area. This may lead to far-reaching consequences that improve the health of Nigerian children in unexpected ways.
Inspiring Ongoing Dedication
In addition to the planned expansion to other regions of Nigeria, Dr. Nwankwor also hopes to encourage continued involvement in the project by Nemours/Alfred I duPont Hospital for Children and Cooper University Hospital, which have been instrumental in the success to date. "It is still perceived as my project, but I want it to be an institutional project," states Dr. Nwankwor. He would like to see the support shift from that of personal support of him to support of the program as a whole.
Many U.S. children's hospitals, including Duke University, Seattle Children's Hospital, and Boston Children's Hospital, sponsor and support global child health projects, including PICUs. This provides invaluable opportunities for staff and trainees on both sides to exchange ideas, teaching, and resources. Partnering with a U.S. hospital provides the infrastructure to maintain these units well into the future and continues to achieve Dr. Nwankwor's meaningful initial goal "to see kids who would have otherwise died live because of this system."
"I tell people that you need to do something that is much more than yourself," Dr. Nwankwor said. Without realizing it, his actions have motivated many others. Dr. Nwankwor describes how his mother recently became acutely ill in Nigeria with what seemed to be seizures, but there was no EEG machine at the local hospital for diagnosis.
When a fellow physician who lived far away learned of his mother's situation, he gladly packed up his own EEG machine and took it to the hospital where Dr. Nwankwor's mother was located. He told Dr. Nwankwor that he wasn't doing it because they were friends, but because he had seen the effect of Dr. Nwankwor's local efforts and felt inspired to do the same to help someone in need. Although he remains humble about his efforts, this sense of inspiration Dr. Nwankwor offers to those in his orbit will undoubtedly continue to motivate positive change in the healthcare world and beyond.
About the Author
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