Thomas Wakley, who founded The Lancet in 1823, would be astounded by medicine today. Progress over the past two centuries has been remarkable. Antiseptics and anaesthetics in surgery, life-saving devices and drugs, childhood and adult immunisation, the development of clinical trials, and digital healthcare, are just a few of the advances that have improved patients’ lives.
There has also been increased scrutiny of medical power, including medical paternalism, the colonial foundations of global health, the inequities of race-based medicine and medical misogyny.
Yet some principles have remained consistent despite the passage of time: trust between healthcare professionals and patients, and the importance of respectful, compassionate care.
In its 200th anniversary year, The Lancet invited submissions for its annual essay competition, the Wakley Prize.
Submissions were encouraged about the five Spotlights of The Lancet’s 200th anniversary year: universal health coverage, health and climate change, research for health, mental health, and child and adolescent health.
The winning essay, Learned Helplessness, by physician Ugochi Okorafor, is a heartfelt account of the importance of universal health coverage in Nigeria.
Okorafor writes about the challenges of caring for a patient in an over-stretched and under-resourced government hospital in southwest Nigeria, where patients must pay for most of the services.
In stark, candid prose Okorafor describes her encounter with a pregnant woman needing urgent care and the barriers she and her colleagues faced in trying to provide it.
This powerful essay highlights the human costs for both patients and health professionals when universal health coverage remains out of reach. Okorafor, who currently works as a medical officer in a private cardiology practice in Lagos, Nigeria, said she was motivated to write this essay because for her, “universal health coverage matters most in medicine”.
“Everything we do exists to serve the public, from research to clinical practice and health advocacy. Yet, all of these would be for nought if, as healthcare workers, we and the people we swore to serve cannot access healthcare.”
Winning Wakley essay by Ugochi Okorafor
It was my first job after medical school, and I barely lasted a week. I started as a house officer at a state-owned hospital in southwest Nigeria a couple of years ago after graduating from medical school.
My first posting was to the obstetrics and gynaecology unit, part of my role being to see all the new patients presenting to the department and then inform my senior colleagues about them.
In the first week, I was called to the ward to care for a young pregnant woman who had presented with swollen legs and headaches in the second trimester. Her systolic blood pressure was high. Until now, she had not been seen by an obstetrician or a midwife and was managing the pregnancy at home. She told me that this was not her first pregnancy, and she had had such complications before.
I admitted her to the unit and called a senior colleague to draft a management plan. This was where I think the situation began unravelling. This patient was guaranteed a consultation because she was an indigene of the state where the hospital was located. But that was all.
The hospital was a pay-before-service facility. Patients needed to pay for basic tests, like an ultrasound and a urinalysis, or prescribed BP medications. Keeping a bed for a non-paying patient like her was a constant fight with the head nurse.
I did not blame the nurse; the authorities would penalise her for letting a non-paying patient stay. The hospital authorities were not to be blamed: funding from the government was inadequate.
The patient was permitted to stay. I saw her two more times that day. No relative had come to be with her. The staff knew this case was serious and had seen such cases play out before. But working under the constraints of the pay-before-service facility, they could not stop it. They had reached their elastic limit.
I was doing rounds early the next day. The woman had survived the night. But when I got to her bed, the nurse said the patient had had seizures overnight. This was now a case of eclampsia.
I called my immediate senior, who called the consultant. The consultant was new; she questioned how we could have left such a critical case without management.
She instructed the ward attendant to tell theatre a patient was coming for an emergency Caesarean. The theatre sent back a message: no receipt, no surgery.
The consultant quickly brought out a wad of cash and asked the attendant to pay and then meet us in the theatre with a receipt. We secured an intravenous line and wheeled the patient to theatre.
True to their word, theatre personnel did not allow us into the suite without showing a receipt. We waited at the door for the attendant, who soon returned with the receipt. The consultant was told the amount paid was incomplete. She promised to pay the rest after the surgery.
I wondered how far she would go for this woman and how many more times this would happen during her career before she reached her limit.
The surgery was quick. The twins were removed. They were dead. The hospital did not have the incubators to nurse them even if the babies, by some miracle, had survived. I was told to get blood ready for transfusion, as the patient would need it.
My mind was spiralling at that point. No relative had come to the hospital, including her husband. If the only way the consultant could perform this surgery was to pay for it herself, imagine my impending struggle with the blood bank.
The surgery was over, and the patient was alive, but barely. She needed oxygen, blood, anticonvulsants, antihypertensives, antibiotics and analgesics, among other medications. She needed intensive care.
This hospital did not have an intensive care unit, so she was to be cared for in the ward.
The consultant left the theatre to settle the rest of the bill. I left to coerce the blood bank to provide blood for this patient. It did not work. Unlike the consultant, I did not have the money to pay for it. It was my first week and it would be a while before I would be paid.
I went to the ward to get the patient’s case notes and try to contact her family. Unsurprisingly, there was no phone number on file for the next of kin or any additional information, apart from my documentation from the rounds and the theatre notes.
The file was just a bunch of papers because she had not completed the payment for admission. So I got hold of her mobile phone to find the last number in her call history.
The thought of all the rules I was breaking did not even cross my mind. I used my phone to call this number. A woman answered. It was not a relative, but someone from her church. I introduced myself and asked for the telephone number of the patient’s husband.
But the woman said he could not be reached because his phone had been damaged a few days ago.
I gave her the barest of details about the patient and she told me she would help find the patient’s husband. She also promised to visit the hospital to assist with the expenses. I thanked her and asked her to call me when she arrived.
I met her at the entrance to the hospital. Without knowing her destination, the visitor was not allowed entry into the hospital premises. I took her to the ward. The patient was still unconscious.
The visitor knew immediately the bills were beyond her. She asked about the whereabouts of the patient's babies. My face had all the answers.
She sighed, said at least the patient was still alive. She brought out some money and went to pay for whatever she could.
That afternoon, I handed over to a colleague and left for my call duty in the emergency department. At that point, the patient had not received the blood transfusions, medications, or oxygen.
Late that night I got a call from a senior colleague. The woman had died. It took an hour for things to slow down enough to leave the emergency department. When I got to the ward, I could see that a large oxygen tank had been placed beside her bed.
Someone had paid for oxygen at least. Her bed had been screened. She was still there.
She could not be moved to the mortuary until someone brought a receipt. The patients on either side of her had dragged their beds away: they were also pregnant and were wary that her misfortune might visit them.
The woman had died alone. Even in death, she was shunned.
Her husband finally arrived. He was distraught. He had lost his wife and their two daughters. The hospital bills were also mounting. He needed to pay the admission fee, the mortuary fee, and the body release fee. He would need to pay a fee for each day she was in the mortuary. At least the surgery was already paid for.
The next day was Friday. The woman had been moved to the mortuary during the night. Early in the morning I handed over the overnight admissions in the emergency room and went to freshen up. There were rounds to be done and we were also running an obstetric clinic.
My workday ended in the late afternoon when I left the hospital for home. After the loss of this patient, I knew I could not keep working there. A week later I returned to the hospital to collect the rest of my belongings.
Being a doctor in pay-before-service health facilities in Nigeria means being exposed daily to the hopelessness of the healthcare situation and knowing you are helpless against it.
There is a saying in Nigeria, “Na person wey don chop dey go hospital”. Loosely translated it means that only those who are well fed go to see a doctor with their complaints. Many people in Nigeria live on low incomes so it is logical they will prioritise spending on food and shelter over healthcare.
Even at the federal government level, the healthcare provided for the masses seems to be an afterthought.
In 2001, African Union countries pledged to spend at least 15% of the yearly budget on healthcare. Nigeria, however, has never met that target and the Health Ministry’s allocation has been consistently below 7%.
Only 5·75% of the budget was allocated to health in 2023.
Nigeria is paying the price for this underinvestment. My country has disappointing health indicators across the board and accounts for more than 20% of global maternal deaths.
I moved on to work for a hospital owned by the Ministry of Defence in the southwest of Nigeria. Army officers and their families had access to affordable and good quality healthcare through health insurance. Patients had coverage for most investigations, medications, and procedures because the Ministry placed the health of its personnel and their families in high regard.
The patients I cared for there received the treatment they needed. But the story is different for many Nigerians, including health personnel, who do not have health insurance and must pay for their healthcare themselves. I am a practising doctor and I have no health insurance.
I wrote this essay with a nagging pain in my left wrist that has persisted for more than a month. An x-ray is probably needed. But I will not get one done. My monthly salary at the current exchange rate is about £160. An x-ray is simply not in my budget for this month or next month.
And I am a physician. I am considered by my society to be part of a well-earning profession. Whether or not I pay for the x-ray, both outcomes are unpleasant.
Further treatments will be required if a pathology is detected. If the x-ray does not show any issue, the money spent on it further diminishes my income.
Much more must be done to deliver universal health coverage. We deserve it. Affordable, quality healthcare must be a right, not a privilege.
The Lancet Wakley essay – Learned Helplessness (Open access)
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