Dr. Adeola Adekunle is a senior resident doctor and trainee surgeon in Lagos. His success is a product of constant learning — even in the midst of a pandemic.

Intermittent beeps from the anesthesia machine permeate the operating room. A ceiling-mounted surgical light beams over the face of Mirabel Nwokorie, a 23-month-old baby, about to undergo a cleft palate repair.

After the anesthetists have put the baby to sleep, Dr. Adeola Adekunle, a senior resident doctor and an oral and maxillofacial surgeon at the Lagos University Teaching Hospital, fits a metal device inside her mouth to keep it open.

A nurse nearby hands him scalpels and scissors on request. Adekunle looks relaxed, focused and unfazed by the task before him.

He occasionally chats to his trainers and colleagues Dr. Olugbemiga Ogunlewe and Dr. Olutayo James, during the procedure. Sporadic chuckles and banter among the team add a spark of liveliness to the room

The surgery lasts for over two hours. As she wakes up, Mirabel starts to whimper.

Beads of sweat line Adekunle’s forehead as he removes his scrub and gloves. He settles into a plastic chair and fills out a form.

Adekunle says he loves the rapid transformation and relief cleft lip and palate repair surgeries bring to both patients and their families.

“The biggest motivation for me … is the joy we put on the faces of the parents of these children,” he says.

A father of two, the 35-year-old surgeon didn’t see himself becoming a doctor when he was in junior secondary school.

“I hated being in hospitals,” he remembers with a smile.

Then a close friend had a bone fracture and got admitted to hospital. Adekunle began to visit frequently and the idea of becoming a doctor slowly took hold of him.

He went on to graduate with a degree in dental surgery and a distinction in restorative dentistry at Obafemi Awolowo University in 2010.

But Adekunle’s education doesn’t end there. He continues to undertake more training programs to become adept at cleft care. Smile Train is partnering with the West African College of Surgeons to provide an annual nine-month fellowship training program on cleft care to surgeons across West and Central Africa. The postgraduate training, which commenced in training sites in Nigeria, Ghana and Senegal in early July, will groom six surgeons annually over the next five years and help them to specialize in cleft care.

Dr. Adeola Adekunle, a senior resident doctor at LUTH since 2014, explains how training has enabled him to grow his skills and become adept at cleft care.

Since April, he has been taking lessons on comprehensive cleft care on Zoom. Instructors use a mix of text and photos for illustration.

Adekunle says the online training has brought trainees and experts from several West African countries together to share ideas, learn from different specialists and to exchange knowledge and experience.

Usually trainees have to travel to training centers to receive instructions and learn from more experienced surgeons in the theater. In late March, federal authorities imposed lockdowns to reduce the spread of the coronavirus pandemic, affecting mobility and forcing the dental clinic at LUTH to stop operations.

Since April, Smile Train and the West African College of Surgeons have been running a virtual training program in order to overcome mobility restrictions brought in due to the COVID-19 pandemic. The sessions, which take place over Zoom, bring together trainees and experts from across West Africa to share ideas and knowledge.

Nigeria reported its first confirmed case of COVID-19 in late February.

Health authorities scrambled to increase training and equipment as cases spread across the country’s 36 states.

The pandemic exposed the challenges battering Nigeria’s underfunded healthcare system. In 2017, Nigeria’s health expenditure as a share of GDP was 3.76%, compared to South Africa’s 8.11%. Since 2016, Nigeria’s budgetary allocation to the healthcare sector as a share of annual federal budget has been below 5%, significantly lower than the 15% African nations agreed to allocate to their health budgets during the Abuja Declaration meeting in 2001. Out-of-pocket expenditure still accounts for over 70% and the National Health Insurance Scheme, launched in 2005, has only achieved some 5% coverage.

Several decades of neglect has created huge gaps in health infrastructure, medical supplies and personnel. It also fueled medical tourism, with Nigerians spending at least $1 billion per year on medical bills overseas. The density of medical professionals to the population is also abysmal. Nigeria has only 3.8 medical doctors per 10,000 people, 5.6 nurses per 10,000 population and 0.22 dentists per 10,000 people.

Poor remuneration and infrastructure, and lack of medical supplies has led to brain drain in the health sector. Nigerian-trained health workers constitute the third largest group of foreign-trained doctors working in the U.K. Over half of the estimated 72,000 doctoMuyiwa Rotimi, consultant anesthetist and a member of LUTH’s COVID-19 response team, urges the government to prioritize funding and regular training for healthcare workers.

“If we don’t start now, we might find ourselves in the same place after five years,” Rotimi warns.

Until LUTH began a partnership with Smile Train in 2007, cleft care was largely limited to surgical repairs. But to provide comprehensive cleft care, a team consisting of surgeons, anesthetists, speech therapists, nurses, ENT or ear, nose, throat surgeons, orthodontists, nutritionists, and social workers are allrs registered with the Medical and Dental Council of Nigeria work outside of the country and a Several decades of neglect has created huge gaps in health infrastructure, medical supplies and personnel. It also fueled medical tourism, with Nigerians spending at least $1 billion per year on medical bills overseas. The density of medical professionals to the population is also abysmal. Nigeria has only 3.8 medical doctors per 10,000 people, 5.6 nurses per 10,000 population and 0.22 dentists per 10,000 people.

Poor remuneration and infrastructure, and lack of medical supplies has led to brain drain in the health sector. Nigerian-trained health workers constitute the third largest group of foreign-trained doctors working in the U.K. Over half of the estimated 72,000 doctors registered with the Medical and Dental Council of Nigeria work outside of the country and a new ‘Health and Care Visa’ policy launched on July 15, 2020 by the U.K. government and open to Nigerians, may encourage others to follow.

Current health expenditure (% of GDP) 2000-2017
Source: World Bank

Muyiwa Rotimi, consultant anesthetist and a member of LUTH’s COVID-19 response team, urges the government to prioritize funding and regular training for healthcare workers.

“If we don’t start now, we might find ourselves in the same place after five years,” Rotimi warns.

Until LUTH began a partnership with Smile Train in 2007, cleft care was largely limited to surgical repairs. But to provide comprehensive cleft care, a team consisting of surgeons, anesthetists, speech therapists, nurses, ENT or ear, nose, throat surgeons, orthodontists, nutritionists, and social workers are all needed. These specialists needed to be trained in cleft care, and cleft surgeons trained to work with them.

Professor Ronke Desalu, consultant paediatric anaesthetist at LUTH, explains how the pandemic affected the delivery of services and health worker well-being at the hospital.

Additionally, the cost of care, stigma, and lack of awareness meant LUTH treated fewer than ten cleft patients annually, says Professor Olugbemiga Ogunlewe, chief cleft surgeon and head of LUTH cleft care team. According to Dr. Adekunle and Dr. James, a cleft lip and palate surgery costs between 150,000 to 200,000 naira (USD395 to USD526), a fee that most Nigerians from lower socioeconomic backgrounds cannot afford.

Since it began its partnership with LUTH, Smile Train has improved access to training and medical equipment while funding cleft lip and palate surgeries. A survey in 2017 found that 84% of cleft surgeons interviewed were working in university teaching hospitals. Cleft surgeons in LUTH now perform at least Mirabel is just one of the patients currently experiencing the benefits of this partnership and commitment to training of health professionals.

Outside the operating theatre complex, Ijeoma Nwokorie, Mirabel’s mother, waits with trepidation.

Around 1 p.m. she reunites with Mirabel, her eyes full with emotion.

Adekunle reassures her that her baby is in perfect condition and instructs Nwokorie to prevent the baby from touching her mouth.

“She will be fine,” he declares, his tone upbeat.

At the hospital ward, Nwokorie looks over Mirabel as she sleeps in her arms.

Nwokorie remembers how startled she was after noticing a hole on the roof of Mirabel’s mouth some weeks after her birth. Food and liquid leaked out of her baby’s nose, too. Doctors at a private hospital told her nothing was amiss. Herhusband, too, said that was how “her own God created her”.

A year later, when she birthed another baby who didn’t have a cleft palate, her fears heightened.

A friend told her the surgery can only be performed in the U.S. Confused and anxious, Nwokorie turned to the internet.

“What causes a baby to have a hole in her mouth,” she remembers searching on Google and breaks into laughter.

“Can cleft palate surgery be done here in Nigeria,” she recalls typing again. That was how she found LUTH, visited in January and then learnt that Smile Train covers the cost of caring for the baby, including the palate repair.

“I could not believe … that Nigerian doctors did this miracle,” Nwokorie says after the surgery.

Ensuring patients and their families can receive care close to home has been one of the training program’s main goals.

“We want to train people who can stand on their own and go and help these babies wherever they are established,” he says, citing the example of a Béninoise surgeon who was sponsored by Smile Train to receive cleft training at LUTH last year through the WACS fellowship program. After the cleft training, the trainers helped the surgeon to set up a clinic in N’Dali city in northern Benin Republic.

“When you train people you get more services to people in remote areas,” he says, adding that the Béninoise surgeon sends pictures via WhatsApp whenever he has any complicated cases and they guide him through it.

Four hours after the surgical repair, Adekunle visits the pediatric ward to check Mirabel.

He chats with the mother about the baby’s condition and encourages her to stay positive. He goes over his previous instructions about feeding for emphasis.

“By Tuesday she will be discharged,” he tells her.

Just before nightfall, Adekunle ambles to his car parked by the entrance of the towering dental clinic. “When it gets done it is a big relief,” he says of the cleft surgery. “You just know that this is another [case] that has been sorted [out] so we move to the next one.”

He looks tired and doesn’t walk with his usual brisk gait. He makes small talk with a colleague who is turning on his ignition. They both smile and make farewell gestures before

his colleague drives off.

Quizzed on his future plans after his senior residency training, Adekunle prevaricates.

“I don’t know yet; I really cannot say,” he remarks, reflecting for a moment.

Would he stay at LUTH if the conditions are right?

“Yes I will,” he says.