The Export

The Export

I got a message the other day informing me of the death of one of my patients. This was unexpected. He was mostly healthy, in his early 70’s, but had recently developed an infection. As part of his recovery, he had been in a rehabilitation home. His wife told me that he had actually been doing quite well the day before, but in the morning he was found to have passed away in his sleep.

I was deeply saddened by his death, but did my best to comfort his wife. As with most of my patients, I had developed a relationship with both him and his wife. He had led a fascinating life. This his story.

He was born to a father who was a professional golfer. As he grew up, he took up playing golf. He however could not make it as a professional golfer. He then gradually got involved in helping to build golf courses. In particular, he developed an expertise in using a bulldozer to help shape the golf course grounds.

He joined a golf course construction company. The golf courses would be designed by an architect, and he would lead a team to bring the architects vision to life. He was involved in building many golf courses in the United States.

He then came to me one day and told me that he will be away for several months as his company had got a contract to build golf courses in China. I was taken aback? Why China? Apparently with the new found prosperity in China, golf is becoming more popular. Many golf courses are being built and American companies are the best in the business. They take their own crews who work with local groundsmen to build the courses.

The company would arrange for apartments for the American crew to live in at the site of the golf courses. Most of these golf courses were in relatively remoter locations that foreigners do not typically go to. He told me that cuisine was often a challenge as American food was usually difficult to get. His wife would be with him. I had to ensure that they would have their prescriptions filled for six months at a time before their trip.

He built many golf courses in China and other nearby countries such as South Korea until he retired. He would see me for his medical appointments during his visits home and share with me some of his experiences.

Interestingly, I was watching the news about how America has a large negative trade balance with China and imports all kinds of goods from them. However, in terms of golf courses, it is the other way around.

I hope my patient is now at peace at a golf course in heaven. 

The Lost Boy

 

The Lost Boy

It was 2003, and I was doing a fellowship in Infectious Disease. As part of the training, I was in the Infectious Disease clinic one day. A patient showed up with an African sounding name and the reason for the visit was listed as ‘Leprosy.’ I was intrigued. I had grown up in West Africa and seen a fair amount of Leprosy there. I went in to see the patient. He was a young man, tall and dark. He was from the Dinka tribe of Southern Sudan. He did not speak English but had a friend as a translator. He had successfully completed his treatment for Leprosy and was cured. He however also had HIV but was well controlled on treatment. He was doing well, and I completed my visit.IV and was well controlled on treatment

Later, when I was discussing the visit with my attending, he asked me if I knew anything about the ‘Lost Boys of Sudan?’ I had heard the term, but did not know the details. He then told me that the country of Sudan in East Africa had a civil war. The Second Sudanese Civil War was a conflict from 1983 to 2005 between the central Sudanese government and the Sudan People's Liberation Army. It lasted for almost 22 years and is one of the longest civil wars on record. The war resulted in the independence of South Sudan six years after the war ended. Roughly two million people died. Four million people in southern Sudan were displaced at least once, normally repeatedly during the war. 

Many children were orphaned or separated from their families because of the systematic attacks of genocide in the southern part of the country. Some children were able to avoid capture or death because they were away from their villages tending cattle at the cattle camps and were able to flee and hide in the dense African bush. Children were highly marginalized during this period. As a result, they began to conglomerate and organize themselves to flee the country and the war. Motivated by the loss of their parents and their need to find food and safety from the conflict, an estimated 20,000 boys from rural southern Sudan (mostly Dinka and Nuer tribes) fled to bordering Ethiopia and Kenya.

Much of the travel took place by foot in large groups with the boys traveling in single file lines. The journey from South Sudan to the nearest refugee camp could be up to thousands of miles. Travel ranged from a span of weeks to two or more years. Often, the children traveled with no possessions besides the clothes on their backs. The Boys often depended on the charity of villages they passed for food, necessities, and treatment of the sick. Groups of Boys were often organized and led by the oldest boy in the group, who could be a young adult or sometimes as young as ten or twelve years old. Some made it to refugee camps in Ethiopia and Kenya. The name "The Lost Boys of Sudan" was given to them by workers at the refugee camps.

In 2001, as part of a program established by the United States, and the United Nations High Commissioner for Refugees (UNHCR), approximately 3,800 Lost Boys were offered resettlement in the United States with assistance from charities in the United States. They are now scattered over at least 38 cities, including major metropolises such as Chicago, Dallas, Boston, Seattle, and Atlanta. Halted after September 11th for security reasons, the program restarted in 2004. As of 2006, the largest population of these refugees in the United States was in Omaha, Nebraska, which hosted about 7,000 people. 

Our patient was brought over by the Lutheran Church. He did not have the health screenings that most immigrants get prior to coming and was found to be positive for HIV infection on arrival in the United States. He was started on treatment and was doing well but then developed an anesthetic spot on his arm. This was biopsied and found to be leprosy. He was started on treatment and sent to one last remaining Leprosy treatment center in Louisiana.

My attending then told me the story of trying to get him on a Delta flight to Louisiana. He said, it was difficult to convince the airline that this patient had active leprosy but was not a risk to the other passengers. He had to write official letters to convince them.

Many of the lost boys had difficulty assimilating in America. A large number had post-traumatic stress disorder. In January 2011, 99.47% of South Sudanese voted to separate from the north and become an independent nation. Some American former Lost Boys now hold positions in the current government of South Sudan.

My patient had appeared to be doing well, despite his inability to speak English. I hope he continues to do well today.

The Agama

 

The Agama

I was recently watching a show on the Disney channel called ‘Iwaju.’ It is an animated show made by three Nigerian movie makers and the story is based in a fictionalized version of Lagos, the largest city in Nigeria. I had grown up in Nigeria but have lived in the United States for the last thirty years. The language of the movies was ‘Pidgin’ English, a version of English that I am very familiar with. Nigeria has over 140 languages, and this version of English often serves as a lingua franca in Nigeria. I was having fun watching the show with its futuristic depiction of Lagos, when a new character appeared. It was an Agama lizard.
 
The Agama lizard in the show was a robot, designed to protect the young heroine of the show by her father. However, it brought a lot of nostalgia for me. Agama lizards are ubiquitous in Nigeria. They are everywhere with their flaming orange necks and purple blue bodies. I have not seen them anywhere else, but I hear that they are now spreading in the state of Florida in the United States. They likely came here as escaped pets and the consistent warm and wet weather, a fast reproduction cycle and no natural predators have helped their spread. They have a fiery appearance with a flaming orange neck and dark blue and purple bodies. As reptiles they have poor ability to control their internal temperature and would often be seen warming themselves in the sunshine. They also tend to nod their heads at regular intervals. They are fairly harmless.
 
Their head nodding reminded me of an incident of my childhood. In the early 1980’s I was attending Barewa College, in Zaria, Nigeria. In those days, this was an elite high school in Northern Nigeria. At that time, we had a new principal, Mr. Ishaq Nuhu. He was only the second indigenous person to hold this position as previous principals had been mostly British men. He was a most dignified and refined person but during our daily recitation of the national anthem, he tended to nod his head. Thus, the students promptly decided to nickname him ‘Agama’. This name became so synonymous with him that I forgot his real name and had to look it up.
 
On another day I was playing with my good friend Shuaib. We must have been 11 or 12 years old then. Shuaib was American. His father had converted to Islam and moved to Africa in the late 1960’s from Boston. I attended Barewa College with Shuaib and his brother. On that day Shuaib had found some catapults. Shuaib was good at hitting targets, but I was lousy. In the yard we came upon a bunch of Agama lizards sunning themselves on a fence. Now we were not cruel kids, but in our foolishness challenged each other to see if we could hit the lizards. Shuaib went first and missed despite being an excellent shot. I went next and being a poor shot, never expected to hit anything. However, the Agamas had realized someone was shooting pellets at them and were scrambling, and one came right in the path of my pellet and got knocked off the wall. He however must have been okay as I saw him scrambling away.
 

This lucky hit scared us and we both ran off. I do not think I ever played with a catapult again! Watching this movie brought all those childhood memories back. The population of Agama lizards is now gradually spreading in the United States, maybe I will run into one again. This time I will not be hurling any more pellets at them.

The Pacemaker

 The Pacemaker

Many years ago, I started a residency in Internal Medicine in the United States. I had grown up in West Africa and gone to medical school there. I then started training in Orthopedic Surgery there but after two years I realized that this was not for me and I decided to go into Public Health.

I came to the United States to do a Masters in Public Health. While I was doing this I realized that being a practicing doctor would allow me to have more impact in Public Health, and thus I came to North Carolina to do a residency in Internal Medicine.

It did not start so well. On my first day, I met our team. My fellow intern was this tall man from the Midwest who was actually a Psychiatry resident doing his Internal Medicine rotations. We were both posted to Cardiology which was considered the toughest rotation in our program.

On our first day we met our senior resident. A smart, and handsome young man, he looked at us and said with some annoyance - I cannot believe they gave me a Psychiatry resident and a Foreign medical graduate! “They must be scraping the bottom of the barrel”! That did not make us feel good. Then we met our attending Professor R. He was an older physician who did not smile at all and appeared quite stern. We felt even worse.

That first day, I was seeing a patient who complained of some chest pain. I ordered an EKG and then rushed to join rounds. I then mentioned to Professor R about the chest pain and that I had ordered the EKG. Professor R looked at me severely and said - and you left him there? And then he rushed to the room. The EKG was just done and the patient was fine. I was however given a big lecture of never leaving a patient with chest pain alone. Needless to say, my nerves were shot.

The next day we were seeing another patient, Mr. A, who had developed a heart block. We discussed him in rounds and Professor R said that he needs a Pacemaker. I was instructed to explain this to the patient and get consent. I went to him and spent a long time explaining everything to him and asked for consent. He refused.

Now I was in turmoil as I failed even in this simple task. I went back to Professor R and told him. He was not happy. He got up and walked straight to the patient's room and asked him, why did he refuse? It was then Mr. A said he was a Palestinian from the West Bank. He said that if he had a pacemaker, he would not be able to get through the metal detectors and security manned by the Israelis.

I then saw Professor R’s face change. He looked extremely sad and much softer. I found out later that he was Jewish. He then sat on Mr. A.’s bed and started talking to him. He explained to him how important this was and he would provide all the documentation he needed to get through the checkpoints.

Mr. A agreed to the procedure and the pacemaker was implanted in him. Every day on rounds the usually reserved Professor would sit down with Mr. A. and laugh and talk with him. Mr. A made a complete recovery and was discharged with the detailed paperwork from Professor R.

The bond between a Jewish doctor and his Palestinian patient made a deep impression on me. This still gives me hope that one day our mutual humanity will be paramount and wars will be a thing of the past.

Monkeypox

 

Monkeypox

It was another day in the office in the small town where I work as an Infectious Disease Physician. The phone rang. It was one of the nurses in the Emergency Room. She said to me that they needed me to see a patient immediately as the patient had been exposed to Monkeypox.

Monkeypox? I struggled to recall this disease. I asked the nurse for details. She told me that the patient had been on a flight from Lagos in Nigeria to the United States. One of the passengers on that flight got sick and developed sores on his face. He was admitted to a local hospital in Dallas. A biopsy of one of those lesions came back as 'Monkeypox'. All the other passengers on that flight were considered to have been exposed.

Monkeypox is a pox virus of the same family as Smallpox. It is called Monkeypox because the first outbreak occurred in some research monkeys in 1958. The first human case was described in 1970. It is thought to spread from rodents. It still occurs rarely in parts of Africa. There are two variants. The less lethal one is found in West Africa and has a 1% mortality, but transmission is rare. A central African variant is more easily transmissible and has a higher mortality of 10%.

There have been sporadic cases. There were a few cases in the United States in 2013, acquired from infected pet mice imported from Ghana. There have been none since then until this case in 2021. There was an outbreak in Nigeria from 2017 to 2019. Treatment is mostly supportive. The incubation period is 7 to 14 days. Luckily on this flight everyone was wearing masks because of the Covid outbreak, so risk of exposure was low.

Once the first passenger was diagnosed, the CDC aggressively traced every other passenger on that flight and put them under surveillance. They could not find two of those passengers, one of whom was our patient. The CDC then put out an alert to all the hospitals with the names of the missing passengers. Our patient had come to visit family near our hospital. She had forgotten her regular medications and came to our Emergency Room to get these prescribed. Once she got there, the system flagged her and she was put in isolation. She could not understand what was being told to her and I was told she could not speak English.

I saw her through telemedicine. She appeared very frightened. I had been born in Pakistan, but grew up in Nigeria. I was familiar with a form of English spoken in Nigeria called 'Pidgin English'. So, I decide to try that and said to her "Madam, how you de", Wetin happen? (How are you, what happened)?

She was taken aback to see a South Asian man speaking pidgin but instantly understood me. “I de fine” (I am fine) she said. Make una help me (please help me). I talked to her for some time and calmed her down. She asked for some food and I told her that I will ask for dinner for her, but could not arrange pounded yam and egusi (typical Nigerian dishes). She laughed. We got friendly and she told me that she worked in a market in Lagos. I also told her about growing up in Nigeria.

She had no symptoms and it was a month after the flight (well beyond the typical 14-day incubation period). I recommended that no further monitoring was needed and she was subsequently discharged from the hospital. I had never imagined that my knowledge of pidgin English will come in use in this way. I hope my patient is continuing to do well.

 

Monkeypox lesions

 

The Pandemic

The Pandemic

In December last year, we had been hearing of a new virus called Covid 19, that had been causing a flu like illness in China with many deaths. In February we started of hearing of cases in the United States. In March I saw my first patient.


Being an Infectious Disease doctor with an Epidemiology background, people started asking me questions on how to treat this. Unfortunately, this being a completely new virus, I did not have much advice. I did try to follow the studies out of China and Europe judiciously.


One study out of France suggested using an antimalarial drug called chloroquine. I was very familiar with chloroquine having used it both personally and on patients in West Africa. It was not clear why this would be effective. This drug does have an immunological effect and one reason for death in these patients is an immune phenomenon called adult respiratory distress syndrome. Perhaps chloroquine was able to control this?


We started using this on our patients along with other supportive care. The first patient did very well, and recovered completely. The second patient developed complications and despite heroic efforts by our in-patient team, he died.


At this time, my hospital got a call from a national medical TV show. The patient who had recovered had been giving interviews of how he got better on chloroquine. They were interested in talking to me especially if I had used chloroquine before. My hospital arranged an online interview.

In the interview I told them that I did not know if chloroquine helped or not as one patient had recovered and one had died. They must have been unhappy with my answer, as the interview never aired. Subsequent studies appear to show no benefit from chloroquine and I stopped using it.


The epidemic continued relentlessly. We had a few more patients die and several recover. I was instructed to start consulting on patients via telehealth to limit the number of people in the hospital as well as to  protect me. The virus is unpredictable with some elderly patients with multiple problems doing well, and some younger and healthier patients not doing so well.


One scene will always live with me. Earlier in the epidemic, I had come to the ICU to see a critically ill Covid patient with multiple medical problems. The family had however decided to make him comfortable and the ventilator had been removed. He was dying all alone.

It was at that time that three of the nurses put on their personal protective equipment and went into the room with him. They stood around him, one of them holding his hands until he passed. The sight of those nurses standing quietly by this patient so that he would not die alone touched me deeply.


I do not know how this epidemic will end, but one thing I do know for sure is that it will not rob us of our humanity.

Me in Personal Protective equipment in March 2020

The Migrants

The Migrants

June 20th is world refugee day. Recently, I was reading about the sinking of yet another boat taking migrants from Africa to Europe. This time it was a boat taking West African migrants to Greece. The boat sank, and many lives were lost. Men and women mostly young people in search of a better life. Those that do make it across have further daunting challenges. Seen as nuisances and illegal, they are often locked up in internment camps for years before being deported back home.

The circumstances were different a generation ago. I was seeing an elderly patient of mine today. He became excited when I told him I had grown up in West Africa. He was born in the small Greek island of Kefalonia. He was 18 when in August of 1953 a major earthquake hit that area. Many were killed and most homes were destroyed.

My patient had lost his home and was sleeping in the open. There were no jobs. It was then a cousin convinced him to come to Africa where a family member was running a store. My patient made it to Rhodesia (current day Zimbabwe). He started in business trading in goods all over Africa, and was quite successful. He has very fond memories of those days in Africa remembering it as a beautiful place with wonderful people.

I had grown up in Nigeria and was reminded of another famous Greek merchant there, Anastasios George Leventis. Mr. Leventis moved to Nigeria in the 1920’s from Cyprus and was very successful as a trader. He eventually established the Leventis chain of superstores which were found all over Nigeria.  I remember going to these stores while growing up. 

Mr. Leventis was very friendly with the leaders of newly independent West African states such as Ghana’s Kwameh Nkurmah, who appointed him as Ghana’s ambassador to France. Mr. Leventis died in 1978. After several years his stores eventually closed down, but the A.G. Leventis foundation remains active and provides many charitable activities.

As for my patient, he eventually migrated to the United States in the 1970’s and settled down here. He subsequently got married and had children and grandchildren. He is in his seventy’s now and loves talking about his time in Africa.

However with time, things have turned full circle and migrants are now going the other way to Greece and other European countries from Africa.

I wish that a day will come when no one is forced to migrate for economic or other reasons.

Old Leventis Headquarters in Lagos, Nigeria

Nicknames

Nicknames

I went to medical school at the Ahmadu Bello University in Zaria, Nigeria many years ago. My classmates were a varied bunch of people from different places, different ethnicities, different languages and so on. Yet, the rigors of medical school made us bond for a lifetime. Even today, when many of us have not seen each other in so many years, those bonds remain.

One way we marked our kinship was to give nicknames to each other. Some of these were as simple as shortening the name and adding an ‘O’ at the end in true Northern Nigerian style. I thus became Sifo (from my first name Asif). David became Davo, Isiyaku became Skimo, Mikhail was Miko and so on. Auwal became Walo, but we had two Auwals in our class, so we differentiated by calling one Walo white (slightly lighter skin tone) and the other Walo black.

Some names were initials. We had a CCC (CC Okafor), IYV (Isah Yahyah Vatsa), MSS (Mohammed Sani Shehu) and MBD (Mohammed Bello Dikko). Some were a corruption of the actual name (Ado Zakari Kudan became AZ kudanese and Zara became Zarams). Temple was always known as Temples. Even he does not remember how the S was added to his name.

Some names were based on a certain character of the person. Prof (Emmanuel Ameh) got his name because of his immense knowledge. Iliya Jalo was always smartly dressed and his boyish good looks got him the name Oyiboyish. Goli was short so he was called Brevis and his close friend Agaba was tall, so he was called Longus (from names of muscles in the human body).

Not everyone had nicknames of course, but our bonds were just as strong. So many years later, I still remember my brothers and sisters as it were yesterday. We are scattered all over the globe and practicing medicine in different specialties, but remembering those nicknames we had for each other brings back wonderful memories. 

To me these names represent an amazing fellowship that we had so many years ago that I miss dearly today. Here is a list I made as to the best of my memory;

1. AKA -Alakija Salami
2. Alhaj Bobo -Kabir Sabitu
3. Anastomosis -Moses Audu
4. Ayour -Ayo Oyewo
5. AZKudanese -Ado Zakari
6. Brevis -Lamar Goli
7. CCC -CC Okafor
8. Chi Chi -CC Ekwempu
9. Computer -Ibrahim Mohammed (IM)
10. Davo -David Ewaoda
11. Frikkado -Farid Tahir
12. Fusco -Furera Sule
13. Geeno -Mohammed Yakubu
14. IYV -Isah Vatsa
15. Jugul  -Bitrus Danboyi
16. Lizzie -Elizabeth Ogboli
17. Longus -Emmanuel Agaba
18. MabJo -Mela Mansfield
19. Mallam -Ahmed Yakubu
20. MBD -Bello Dikko
21. Medo -Ahmed Girei
22. Miko -Mikhail Yusuf
23. MSS -Sani Shehu
24. Mr. T -Taiwo Irinoye
25. Nash -Ibrahim Nashabaru
26. Oyiboyish -Ilya Jalo
27. Prof -Emmanuel Ameh
28. Ralour -Tony Akpotabore
29. SamP -Sam Epelle
30. Sankas -Robert Sanda
31. Sifo -Asif Zia
32. Sikkiways -Sikiratu Kailani
33. Skimo -Mohammed Isiyaku
34. Temples -Amaefulla Temple
35. TSW Anya -Daniel Tswanya
36. Verna -Veronica Ubakanma
37. Walo black -Auwal Abubakar
38. Walo white -Auwal Abubakar
39. Zarams -Zara Mairami

Faculty of Medicine, Ahmadu Bello University

The Consult

The Consult

It was spring and I had just returned home from a long day at work, when the phone rang. It was my mother calling from Florida. My father had taken ill suddenly and had to be rushed to the hospital. He was in his eighty's and had been in poor health for a while. He had heart disease and Diabetes and had been undergoing treatment for diabetic foot ulcers.

I called my sister who lived close to them. She was in the hospital with him. She said it did not look good. Both his heart and kidneys were failing and he was being admitted to the intensive care unit. I immediately arranged for a flight to Florida the next day. My brother and other sister were also rushing there.

The next day all four siblings met at my father's bedside in the hospital. It had been several months since all the siblings had been together. The doctors told us that he had suffered another heart attack, and this time he had badly damaged his heart. His heart was failing and his kidneys were failing too. He continued to decline and having difficulty breathing. After three days in the intensive care unit, we as a family decided to make him primarily comfortable.

He was placed on morphine and moved to a regular room. He looked much more comfortable and we all took turns staying at his bedside. He was then moved to a hospice center. I was sitting next to my father in a darkened room. He looked quite comfortable, and I was reflecting back on his life, when suddenly I received a text message on my work phone. It was from one of our resident doctors back in North Carolina.

He had an interesting patient. It was a visitor from Africa, who had come down with Malaria. I was the only Infectious Disease physician in my hospital and thus the request for advice. I texted back my suggestions for treatment. Doing this actually helped me deal better with my father's illness. Early next morning my father passed away peacefully in his sleep. I and one of my sisters were at his bedside.

After this, we got busy with funeral arrangements and taking care of my mother. My colleagues at the hospital were very kind and send many condolences. One of the residents at the hospital even got a collection of money from the other residents and made a donation in my father's name to the Diabetes foundation. They also arranged for a tree to be planted in his name at a state forest. I was very touched by these gestures.

The day after the funeral, I thought about the Malaria patient again. I had the ability to do a 'teleconsult' using my phone and a tablet computer at the hospital via a secure connection. Medical residents and my physician assistant would examine the patient, then connect me online, so I could directly communicate with the patient.

I did do the consultation and speak to my patient. While he was from Africa, he was of Indian descent. He reminded me of my father, who spend decades in Africa but was also of Indian descent. In a strange way, taking care of him helped me deal with my Father's death. The patient was doing better and the malaria parasite had been cleared from his blood.

Our patient told me that he had come to our small town in North Carolina because apparently this was a manufacturing center of agricultural equipment for the type of large cotton farm he ran in Africa. He was subsequently discharged and went back to his hotel room in town.

A few days later, I was back at work. In the hospital we were consulted again on our Malaria patient. Back in his hotel he had developed abdominal pain with persistent nausea and vomiting and been readmitted. The scan of his abdomen showed a significantly enlarged gall bladder.

At our consultation, we determined that his gall bladder enlargement was a complication of his malaria. The malaria had been cleared, but he had developed this condition called “acalculous cholecystitis”. This is a very rare complication of malaria.

We asked our surgeon to remove the gall bladder, which he did. After the surgery, our surgeon told us that the gall bladder had been removed just in the nick of time as it was close to rupture. Our patient made a complete recovery and eventually went back to Africa.

This was a very rewarding experience for me. Watching this patient's complete recovery helped me heal from losing my father.

I hope this patient continues to do well and is successfully running his farm today.

                                                    

Anopheles mosquito carrier of Malaria