The Exodus of Nigerian Doctors

In July last year, my church hosted an empowerment programme to which we invited the Minister of Industry, Trade and Investment, Dr Okey Enelamah as guest speaker. As convener of the session, I had to introduce Enelamah and I reeled out his impressive list of academic and professional qualifications. What stunned the audience was the revelation that the minister is actually a medical doctor, having read medicine at the University of Nigeria, Nsukka where he graduated in 1985.

At the relatively young age of 33, following a foray in the corporate world from Arthur Anderson (now KPMG Professional Services) to Goldman Sachs, before joining Zephyr Management where he rose to become a Principal in the Johannesburg office, Enelamah founded African Capital Alliance (ACA), one of Nigeria’s leading private equity firms where he served as the CEO until his ministerial appointment in November 2015. The question is: If Enelamah had pursued medicine after his MMBS, and had stayed in Nigeria to practice, would he be as successful as he is today?

The question is important against the background of what happened last Saturday in Lagos, when hundreds of young Nigerian medical doctors converged at the premises of an Ikeja hotel for a recruitment test conducted by the Saudi Arabia health ministry. A few weeks earlier, dozens of others were at the British Council to sit for the regular Professional Linguistic Assessments Board (PLAB) exams that will enable them to emigrate to the United Kingdom to practice medicine.

While I cannot count the number of young professionals I know who have either moved to Canada or Australia in recent weeks (many of them with their families), the case of medical doctors deserves special attention. In addition to the UK and Saudi Arabia, many of them are also heading towards South Africa, United Arab Emirates (UAE) and just about any country where their talents could be put to use in a rewarding manner.

Although the World Health Organisation (WHO) recommends one doctor to 600 patients, the ratio in Nigeria now, according to most estimates is about one to 7,000 patients and it can only get worse. As at February last year, according to figures released by the British government, no fewer than 5,405 Nigerian-trained doctors and nurses were working with the British National Health Service (NHS). Hundreds of others have since joined.

As I once wrote on this page, medical doctors have become one of the most neglected professionals in our society, at least within the public sphere. To make matters worse, whenever they demand what should ordinarily be their entitlement, we are quick to condemn and remind them of their Hippocratic oath to (serve) a society that has scant regard for their own plight. That then explains why many of our young medical practitioners are seeking greener pastures abroad.

Three key indices for measuring the prosperity of any nation are security, healthcare and education. Sadly, Nigeria is failing on all counts. A critical problem in these key areas, particularly education and health, is the warped reward system that too often puts professionals in key sectors at the bottom of the remuneration pyramid.

Before I continue, let me add that I am well aware that there is a global discussion about the remuneration of doctors so the issue is not peculiar to Nigeria. What is peculiar to us is that there is no real attempt to deal with the problem. In 2007, I did a series on the medical profession in Nigeria within the context of global frustration. As I argued in those interventions, basic issues must be addressed if we are to join civilised societies who take the health of their citizens seriously.

Following those publications 12 years ago, I received a mail from Prof. Femi Oyebode, then Head of the Department of Psychiatry at the University of Birmingham, Queen Elizabeth Psychiatric Hospital and Chief Examiner, Royal College of Psychiatrists. Part of Oyebode’s letter read:

“Dear Segun,

“I very much enjoyed your article on doctors. You certainly captured the current tensions in the profession by your use of letters. The problem with medicine is at present worldwide. Our students require a minimum of 2As and a B to get in and the work is tireless for five years. Postgraduate medicine is now mandatory for all doctors; even GPs have to train to be specialists. Yet, remuneration is modest and job satisfaction is questionable because of the changes in the work environment. This is an international problem.

“The World Health Organisation (WHO) has a paper out that argues that governments are trying to undermine medicine as a profession. Whatever the case there is little doubt that for a young doctor the stresses are tremendous and the motivation to continue to do this work, which can only be described as noble, must be internal and self-generated. This year I have been a doctor for 30 years and the privilege of serving others has been fulfilling and continually motivating. But, even I now ask whether I can in honesty advise any young prospective student to take up medicine. Such is the state that the profession is in.”

The series itself was provoked by the response to a young man’s inquiry regarding medical school that I found on a website called NHS BLOG DOCTOR, run by Dr. John Crippen, who was then working with the United Kingdom NHS. Both the letter and Dr. Crippen’s reply are important as we interrogate the challenge of healthcare delivery in our country. Entitled ‘Should Sammy go to medical school?’, the letter says: “Dear Dr. Crippen, do you have anything positive to say on a career in medicine? I ask because I will be applying to university soon, possibly for medicine, and so far the cons seem to outweigh the pros. Competition to get into medical school is crazy-fierce, and yet everyone in healthcare I have spoken to tells me to get out while I still can and become an accountant or a children’s TV presenter or something. So I humbly call upon your mighty wisdom. Are all those straight ‘A’ students so misguided? Or am I just missing something?”

In Nigeria today, majority of our medical doctors who were probably the best students in their secondary school days are now looking at some of their contemporaries in other fields with feelings of regret. Unable to meet basic obligations, many of the younger ones are voting with their feet. But I want to end my intervention of today with Dr Crippen’s response to Sammy’s letter. As I said, I am only using the exchange as an entry point into a fuller discussion on the state of medical practice and healthcare delivery in Nigeria. In the coming weeks and months, we will be examining related issues and I welcome contributions from experts. But first, Dr Crippen: “Dear Sammy,

“There is something special about being a doctor. It slightly changes your relationship with fellow human beings. It entitles you to put that mystical word ‘doctor’ before your name. Yes, I know, lots of other people are doing it too now (the dentists, the vets and so on) but nonetheless, in the medical context it means something special. Practising medicine really is about helping people. Of course, you cannot say that at a medical school interview. The interviewing Dean of Medicine will fall of his chair giggling and ask why you are not joining the fire-brigade. Actually, not such a stupid question. That is also about helping people too.

“In most countries, doctors are reasonably well paid. As a UK doctor you will never be poor. But you will never be rich. And you are unlikely ever to earn as much money as friends of equal intelligence going into different careers. You will have excellent job security and, unless you start having sex with the patients, will never be sacked. How much will you earn? In today’s terms, if you become a GP you can expect £100,000 a year, give or take. If you become a consultant, your NHS pay will be between £70,000 and £90,000 a year before private practice and merits awards. Most consultants do not have a huge private practice, and few make a great deal from merit awards.

“How much money do you want? If you want to live in a salubrious suburban middle class area such as, for example, Kenilworth, and you want to have two cars, a wife who does not need to work, four children all educated privately and a couple of expensive foreign holidays a year, then you are not going to be able to do it on a single doctor’s salary; unless you are a gynaecologist with a large private practice. You could do all that easily if you were a London City solicitor!

“Personally, I would regard working in the city as a lawyer/fund manager/accountant/stockbroker/investment banker as a fate worse than death, but that is where the money is. My wife and I are both doctors. We have four children all of whom are (if it does not sound too arrogant) clever enough to go to medical school. None of them will, and that is not because we have discouraged them. We have a lot of friends who are doctors. I cannot off hand think of a single medical couple who has a child who is going to follow in their footsteps. That in itself speaks volumes. A generation ago, medicine was almost a hereditary career.

“Doing medicine will deprive you of most of your twenties. Both my wife and I spent the greater part of our late youth working every hour in hospitals. Our social lives closed in. Friends who were not doctors lost patience with the fact that we were usually not available and, when we were, we kept dozing off in the middle of conversations. It is not as bad as it was. But shift work is destructive. And now, there is the real possibility of unemployment for young doctors. The government has realised that it is cheaper to use none medically trained staff to do traditional medical jobs and, to an extent, they are getting away with it. Sammy, all I can say to you is that, if the passion burns deep, then you must do it. But if it is just one of several options, then I would look elsewhere. I still enjoy my job, when I am allowed to do it. But, knowing everything I know now, looking down the all-powerful ‘retrospectoscope’, would I do it again? No!”

NOTE: This conversation has just started!

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