Tosan Oruwariye

Tosan Oruwariye is saving lives by building innovative global partnerships that make healthcare technology affordable to people in developing countries.

Though a primary care specialist, Tosan recognizes that by making the necessary technology available, simple secondary medical interventions could help save millions of lives in Nigeria and elsewhere. Starting with dialysis, a basic procedure that can prevent death from chronic or acute kidney failure, Tosan is building global bridges for the sustainable transfer of highly technical health services to developing countries.
Although medical institutions in developed countries sometimes donate medical technology, without maintenance it becomes obsolete. Tosan networks with Western medical institutions and other players to provide equipment, technical assistance, training, and health education to Nigerian hospitals on an ongoing basis. The services thus require minimal capital expenditure, making them significantly more affordable for patients, and they remain functional and up to date. To ensure her model does not rest on unsustainable foreign dependency, the Nigerian hospitals agree to establish the dialysis centers as independent units that supply the service directly to the patients and use the income generated to maintain the center.

Millions of people in developing countries suffer poor health or death simply because they do not have access to the technologies that can save them. In addition, these health problems lead to decreased productivity, lower incomes, and excessive strain on family and government resources. Many institutions around the world strive to bring affordable healthcare to developing countries, but these efforts are generally founded on the charitable donation of medical technology and services, with no sustainable structure in place to ensure continuity and widespread impact.
In Nigeria and other low-income countries, preventable and curable illnesses often result in unnecessary death. For instance, diarrheal diseases are the most common cause of death among Nigerian children. Kidney failure is the end result of many such illnesses in children and adults alike. End stage renal disease (ESRD), as it is called, has increased worldwide, with a projected annual growth rate of 8 percent. Most of the Nigerians affected are in their prime productive years, with 70 percent of them under 50 years of age. Statistics for Nigerian children under 10 years of age do not exist, but a pediatric nephrologist at the University College Hospital in Ibadan estimates that 60 children a year at his hospital alone suffer from chronic renal failure, and over 1,000 have acute renal failure.
For many curable illnesses, countries like Nigeria lack the appropriate technology and technical expertise and training to treat them effectively. In the case of renal failure, in places where the technology is available, patients are treated with hemodialysis, a basic procedure that filters their blood to remove harmful wastes. Similar to many other diseases, while 60 percent of renal failure patients in developed countries receive dialysis, only 1 percent of cases in sub-Saharan Africa are treated. Children generally respond better to dialysis than adults, but most Nigerian children in need of it are left to die. Tosan readily admits that children should not have diarrhea in the first place, but implores that if they do, they should not have to die. Two hours of dialysis treatment can save their lives. Tosan and her collaborators estimate the need for acute dialysis treatment, which involves just one treatment, at the three hospitals in which she is launching her initiative, to be over 2,000 people per month. The estimate for people needing chronic dialysis treatment–three sessions per week–is 150 children and 400 adults.
Even when medical technology is available, it is generally neither affordable nor accessible to the majority of the population, and it often comes donated from developed countries, lying idle as soon as something breaks down. Dialysis treatment facilities in Nigeria are sparse and expensive. The country currently has 80 dialysis machines, of which fewer than 25 are functioning, and only one adult renal transplant unit. There are no pediatric dialysis units. The dialysis machines, like other medical technology provided by the West, have frequent breakdowns, poor technical support, and no spare parts. One nonfunctioning unit that Tosan visited merely needed a new hose, but no one at the hospital could diagnose the problem. Frequent power failures, erratic water supply, and inadequate water treatments also contribute to the limitations of this treatment.
Cost alone, however, is often the most prohibitive factor in healthcare access, exacerbated by a lack of knowledge transfer regarding lower-cost technologies and new medical advances. For instance, over 70 percent of Nigerians with chronic renal failure cannot afford dialysis. Only 5 percent of patients who need dialysis are offered peritoneal dialysis, a less-expensive alternative to hemodialysis. Medical professionals used to have concerns about the efficacy and safety of this alternative, but have more recently identified it as the best option for developing countries as it requires less expertise and technical support than hemodialysis. Few physicians in Nigeria use this option because of a lack of awareness of recent advances in the field.
Tosan is currently focused on the specific problem of renal failure because of its severity in Nigeria and other developing countries and its simple treatment, but she recognizes that the problem of affordable healthcare extends much further. Lack of access to life-saving technology is an obstacle faced by millions of people with a variety of curable illnesses.

Rather than provide medical services, Tosan builds the bridges necessary to create sustainable access to such services. She intends to make dialysis treatment affordable and accessible to both children and adults in Nigeria through a national dialysis program centered in a handful of primary centers that will serve as referral outlets for people needing treatment. The strategic foundation of her work is collaboration between institutions with shared goals and interests. She identifies the institutions and people in the West who are interested in long-term partnerships with Nigeria and can provide equipment, training and education. In addition, she identifies the institutions and people in Nigeria who have the capacity to develop the centers. And finally, she facilitates the initial transfer of resources and helps build a sustainable infrastructure for the centers.
The foundation of Tosan's initiative is the bridges she builds between Nigerian hospitals and other medical institutions. Several organizations in the U.S. and elsewhere participate in the initiative, thus minimizing capital expenditure on establishing and maintaining the centers and reducing the cost of the service to the patients. The Children's Hospital in New York has provided 13 hemodialysis machines for the Nigerian program. The National Kidney Foundation in Singapore and Dialysis Incorporated in the United States offer ongoing technical assistance. Baxter Healthcare Corporation, which manufactures the dialysis equipment, trains local technicians and provides back-up technical support. The company's involvement in the project also provides the opportunity for upgrades and spare parts when necessary. Additionally, it is working with Tosan's organization, AE Healthlinks, to integrate the less expensive peritoneal dialysis so that the Nigerian program can reach more patients. The Children's Hospital at Montefiore in New York offers three- to six-month training for specialist physicians working at the centers, and Dialysis Incorporated recently completed a training program for dialysis nurses at one of the centers. These trainings ensure that the physicians and other medical staff understand the technology and stay updated on advances in the field. Finally, Montefiore has provided extensive patient education materials about renal disease and its management, which AE Healthlinks is translating into the three main Nigerian languages and adapting to the Nigerian cultural and social context.
In addition to the equipment and training, additional in-kind support for the transfer of resources further reduces the capital cost. Virgin Atlantic Airways and Gulf Shipping Agency have covered the transportation of specialists and technicians and the shipping and clearing of supplies and equipment, respectively. Tosan has also negotiated with the Nigerian government to waive all duties on equipment imports.
In order to maximize the effectiveness of her initiative, Tosan has established specific criteria with which she chooses the Nigerian hospitals to participate in the collaboration: infrastructure, expertise, and the willingness to allow an independent dialysis center. She currently covers three states by working with University College Hospital in Ibadan, Lagos State Teaching Hospital in Lagos, and Holy Rosary Hospital in Owerri. She also has begun to work with a fourth institution in northern Nigeria. These institutions already had dialysis units, thus providing a basic infrastructure from which to launch the initiative. With all initial costs covered through the partnerships, the estimated price per hemodialysis treatment is US$4. Peritoneal dialysis will be even cheaper at US$2 per treatment.
AE Healthlinks facilitates the partnerships and administers the project in collaboration with the three hospitals, but the centers themselves, using specialists from the hospitals, deliver the services. Therefore, it is essential that the dialysis centers be sustainable. Tosan's model aims to build in this sustainability so that her organization becomes unnecessary. In order to participate in the program, a hospital must agree to an independent, revolving-door management approach with AE Healthlink's oversight. Funds generated from the service are set aside from the rest of the hospital's funds and reinvested in the centers to ensure that money is available for timely maintenance, purchase of needed supplies, and administrative costs. Each center has four dialysis machines that last 20-30 years, so the need for full replacement is unlikely, and Baxter has offered subsidized supplies. The units also have their own generators to avoid problems caused by loss of electricity. Each center will have two technicians trained by Baxter, which will also provide back-up support. Although Baxter has committed only to the initial four centers, it is engaging the federal Ministry of Health to support the initiative and help AE Healthlinks expand its current efforts.
AE Healthlinks expects to have three centers up and running within the year and to reach over 10,000 people in the next five years. Tosan intends for these centers to serve as a national referral base that will become the foundation for the development of the first pediatric living donor transplant program in West Africa.
Her idea easily translates across borders and medical areas, and she knows that once she makes it work with dialysis in Nigeria, other applications are numerous. She has already received inquiries from institutions in other parts of West Africa and from Nigerian organizations working on disability issues.

Born to a nurse-midwife mother and having watched her parents use a lot of their resources to assist people with healthcare, Tosan developed an early interest in medicine. As she grew up, she participated in a variety of volunteer activities, many in the area of healthcare. After her training at the University College Hospital in Ibadan and a year in northern Nigeria experiencing the impact of culture on healthcare, Tosan decided that her country needed more effective public healthcare programs and that pursuing specialist studies overseas would help her acquire the tools necessary to make a difference.
After three years of training in public health at Yale University in the United States, she moved to the Bronx, New York. As an area with the lowest health index in the United States, she knew she could translate her experience there to the Nigerian context. She pursued training in pediatrics at the Albert Einstein College of Medicine and was later asked to become part of the faculty, where she remains currently. Her time in the Bronx taught her a lot about social issues and advocacy, as she regularly deals with patients who have no insurance. She necessarily became an advocate for poor people, immigrants, and at-risk youth, writing grants for programs to help patients address asthma–one of the most chronic and morbid conditions seen in the Bronx. Tosan quickly recognized that the needs and challenges of poor people in the U.S. are similar to those of poor people in her own country.
Tosan became knowledgeable about renal failure and dialysis when her grandmother in Nigeria began suffering from hypertension in the late 1990s. Unlike most Nigerians, Tosan's grandmother had the benefit of many resources at her disposal, yet she still did not survive. In the process of caring for her, Tosan learned a lot about renal dialysis and realized that a creative solution was necessary to address the significant need in Nigeria. After much lobbying and negotiation, she convinced her own Montefiore Hospital in New York to take on a partnership to help develop dialysis centers in Nigeria. With them on board, she began to pursue all the others necessary to realize her goals. She is now ready to implement her ideas more fully and she plans to leave her current responsibilities at Albert Einstein to spend more time in Nigeria.