Suppositions and investigative medicine (I)
By Ed. B.ATTAH
I feel highly honoured by this invitation to deliver the sixth annual Abubakar Imam memorial lecture. 1 am very glad to be able to give the lecture and to be in the midst of people who acknowledge and respect the sterling contributions of such leaders in medicine as Dr. Abubakar Imam. I knew Dr. Imam by repute. His qualities and contributions have been spelt out in previous lectures, and it is not necessary for me to do that again. Rather, I add to that by paying my respects to a community that recognizes such qualities as worthy of emulation, and strengthening that realization with annual reinforcement by way of a memorial lecture.
Abubakar Imam devoted his life to the care of women and women in pregnancy, and the betterment of society. All obstetric care is preventive. In other words, although conception and delivery are natural processes, care must be taken of them, otherwise things can go wrong. Thus, the obstetrician has an anticipatory outlook, which in a rapidly proliferating population such as ours must be particularly keen. The attitude of the African, and perhaps particularly the Nigerian to rapid population growth is rather peculiar. This is in the background of making boast about biological accomplishments. For instance, it is not unusual to hear, “I have seven children.” Nigerians might or might not have noticed in the national newspapers of August 13, the announcement of Nigeria as the world’s tenth most populous nation. This was generally hailed as a landmark achievement by our great nation. This was on the background of not so great performance in the recently concluded world athletics competition in Canada. The papers further hailed even greater prospects for Nigeria by 2025 when Nigeria’s population will ‘‘surge to 204 million thereby placing it as the world’s seventh most populous country.
In my opinion, , such an attitude to national population growth portrays a great burden on the medical profession in health-care provision and discipline in human behaviour. It must also worry the government a great deal, as it spells abject poverty and its attendant risks. In this lecture, I have chosen to address the medical profession on some aspects of national health. Hopefully, this will interest the rest of the audience.
Permit me to acknowledge two people, the chairman of the board of management and the Chief Medical Director of your hospital, Drs. Long John and Sadiq S. WaIi, Dr. Long John is one of the most widely known doctors in this country, for being the best known or one of the best known students of the first medical school in the country. He earned his reputation through hard work. H is reputation has heen sustained through his career by his positive attitide to the development of health-care and the strengthening of health-care services. Dr. Wali is the ultimate in self-effacement while making tremendous impact through thick and thin. He has been all that we know him t to have been without fuss or pageant. For my part as a cancer worker, 1 know him as one who has spoken to at least one President who would not be caught dead with a cigarette near him.
Serving the memory of Abubakar Imam
Apart from the annual lecture, how have we served the memory of Abubakar Imam? Maternal mortality is one of the accepted criteria for assessing the health and health care system of a country. The current initiative on the reduction of maternal mortality in Africa began in 1987, led by the World Health Organisation. Today, maternal mortality in Africa stands at 1 in16, whereas in Western Europe and North America it is 1 in1,800. Nigeria is among the worst. We certainly are not doing things right, presuming that we are aiming at what the others are, namely respect for the life of our women and a healthy population.
In relatively recent times I have practiced for a little over six years in Arabia. That is longer than I did in Britain, North America or anywhere else in my career except Calabar. I can make some observations, as the influence of the Arabian peninsula on Kano and some other parts of the northern Nigeria is obvious. In United Arab Emirates where I lived, the large emirate of Abu Dhabi has male obstetricians, while the tiny emirate of Ajman only employs female obstetricians. The routine medical examination of students of admission into schools of nursing include pregnancy testing; (most students are married). Obstetric care starts with ultrasound (US) as it does all over the world, except in Nigeria and war zones. As a low population country, there is a national policy for increasing the population, accompanied by good obstetric care and child health services. At the same time, family planning services are available for use as indicated.
On the other hand, my experience of obstetric care in northern Nigeria shows some aspects to be an example of thoughtful planning and care. For instance, in Zaria there is a native maternity hospital in which traditional birth attendants (TBAs) conduct delivery. In the same hospital also are European midwives and some times doctors available to those who wish or need their services, or develop complications. Throughout Africa, native midwives or TBAs are mostly women. However, in some tribes or groups such as my own, when complications, especially delay in delivery occur, men practitioners are sent for. The men have only one functiion, namely, to extract from the poor women the name of the man that she is supposed to have committed infidelity with. In my Ibibio language they utter the dreaded words “Siak owo”. Delivery is expected to become magically free once she names the man. It is no use naming one’s husband. The wise woman names her son or brother or some such harmless individual. What I have described is regarded as a system of medicine.
Technical advances
Advance in science and technology have changed the face of the earth. So have they changed the practice of medicine. Quite a number of basic concepts of medicine have been modified or altered by improvement in the understanding of natural science and technological applications. Indeed, every new invention that is of significance is shortly upon its invention applied to medicine. This is because science has a great opportunity to serve humanity through medicine. Such application also makes a lot of money for the manufacturing companies. This relationship between modern medicine and science makes the funding of health care expensive. Increasing population and health expectations make demands on the health care system of a country. These in turn result in the requirement of public stipulation and regulation. Countries that make the most efficient use of the applications of science are those in which the medical community has led in determining these stipulations and regulations through consensus. Naturally, these are the manufacturing nations. Public awareness is high, experience in public interest regulation or legislation is long, and the medical profession keeps itself up to date through its involvement in the manufacturing processes among other ways.
Systems of medicine
In an African country such as ours, the systems or types of medicine that are in practice are varied. Some have a cultural background, while some are hybrides.
The arrangement is conceptual rather than systematic or by method of therapy. Some of these categories admit of observation and study while others do not. Shallow medicine is an off-hand method that does not study problems over time. There is therefore no accumulation of experience or expertise. The practitioner does what seems to be called for. It may be by way of herbs, conjuration, physical maneuver or other therapy. There is no regard for cause of disease. The system is based on suppositions. When supposition are articulated in some sort of manner, then a system of supposition or superstitution emerges. Much of what is called traditional or trado-cultural medicine would seem to fall into this category. Again the cause of disease is not looked for. Usually, it is assumed to be what the patient is most afraid of, or what the practitioner says. Frequently, it necessitates a certain amount of belief in or fear of objects. Attempts at seeking cause frquently lead to sorcery.
Practice based on the supernatural or spiritual takes the system further. As generally practiced in reference to native deities or Almighty God, the system can be quite complicated when focused on physical rather than spiritual ailments. The seeing of vision replaces sorcery and serves the same purpose. Even when the cause is clear, it is presumed that spiritual power conquers whatev er organism causes trhe infection or the narrow pelvis that is obstructing a baby in the birth canal. This system usually gives consideration to elements that are not part of the symptom-sign complex in the patient. In many instances it stands firmly against any other form of therapy even when the need for such intervention is obcvious. this form of practice is widespread in southern Nigeria at the moment. Noticeably, whenever a visiting team of doctors offering free scientific medicine arrive in the area, such treatment homes are emptied of their patients. This leads me to think that Nigerians prefer scientific medicine to other systems. Scientific medicine is tangible medicine. It seeks the cause of ailments so as to administer the specific remedy. Its fascinatiion with specific cause has some times been a disadvantage in this system. However, in recent times, scientific medicine has developed a holistic approach that takes cognizance of intangible influences on health and disease. The search for specific cause and therapy stands scientific medicine apart from the other categories. This seems to give it a certain edge in serving humanity.
Tangible medicine entails a deep and continuing study of humanity and its environment in all ramifications. Its methods of therapy admit only of evidence of efficacy and efficiency. Not content with the b est evidence for a diagnosis it seeks to establish the extent and severity of disease with the aim of prognosting. In determining these, it insists that its methods must be reproducible and verifiable and capable of separating types or classes of body-changes in a manner that has meaningful biological implications.
This system appears logical to the scientific mind, and has persuaded the scientific world of its usefulness. It has strengthened this through success after success of achieving the seemingly impossible. It has opened the heart of living people and effected repair, then replaced the heart with another person’s or an animal’s heart or a machine. It has stopped quite a few ravaging epidemic and plagues. It has made the blind see and the lame walk. It has participated in creating a complete animal. In all these, it has made its methods public and open to debate and criticism, bearing in mind its limitations. Having learnt to admit some treatment forms of other systems as complementary, its place in society appears secure and its progress unstoppable.
However, the colossal failure that it has experienced in Nigeria and some other African states means that there are problems that are difficult for scientific medicine to overcome. In Nigeria, the devastation of the health services in the many years of military rule is presumed to be a major factor. I accept this. It is our duty to identify other factors. While I shall not put forward a treatise on this matter at this lecture, the low level and in some localities absence of science in the society constitutes a major impediment to the acceptance of scientific medicine.
For the rest of the lecture, I shall invite the practitioners of this system of medicine in Nigeria to look inward at the profession and its practice. I do this because of lapses that are everywhere observable and perhaps commonplace. Some of it seems, to reflect gaps between what is readily available between medical knowledge and what doctors do know, while some appears to be regarded as a part of the lassitude that has occured in the general society. By lassitude, I mean a disinclination to exert on interest oneself. This affects the mode of medical practice. The illustrative cases that I shall describe are true.
Society influences in determining the mode of practice
Who determines the mode of medical practice in a country? The society does through several means. The general population may express itself through its attitude to practitioners, remarks in the media and representatiion to the body of the profession. Legislative stipulatiions are the norm, stating expected standards of practice. The profession itself is in most countries expected to lead in determining standards and making sure that the standards are followed. In default, the mode of practice may become opportunistic or alibi medicine rather than evidence based and holistic.
Opportunistic medicine is practiced by a qualified doctor but without due regard to the care of or concer for the patient. It has an element of the mercenary but does not pose sufficient menace to attract the wrath of peers or the law. Alibi medicine habitually makes excuses for its failures. for instance, the doctor did not do a chest x-ray in a patient who turned out to have miliary tuberculosis because the patient had presented with abdominal distension rather than a a history of cough. Or the patient could not afford an x-ray examination. At the back of the doctor’s mind is the presumption that the patient was going to receive full treatment whenever the diognosis was discovered, so it did not really matter. Well, the doctor is wrong in every aspect. In fact, such a way of thinking is an indication for continuing education or retraining. Case histories of this type are now common even in our teaching hospitals where continuing education is presumed.
The aims for diagnosis
The aims on the profession is tremendous. Doctors were traditionally taught to diognose led by the symptom sign complex and elucidated abnormalities of form and function or other bodily expressions of an ailment. This approach remains valid to a good extent. However, advances in scientific medicine have had a tremendous impact on such an apaproach.
For instance, the classical sign-symptom complex for cancer of the stomach was taught as the three. As namely, anaemia, anorexia and asthenia. These are not the signs and symptoms of gastric cancer in today’s medicine. They are the signs and symptoms of a person who had died of stomach cancer and has walked into the clinic because the doctor had forgotten to issue a death certificate. At the time that medicine regarded the three. As the symptom-sign complex of stomach cancer, there was no effective treatment for cancer. So it was not of great significance how or when the disease was diagnosed. Since the application of effective treatment modalities, it has become necessary to diagnose gastric careinioms at an early stage in which therapy may be effective. The technology of double-contrast barium meal and the arrival of fibreoptic endoscopy have changed the gastric cancer scene.The clinical presentation has had to be modified so that clinical assessment would not stand in the way of good medicine. The clinical presention of cancer of the stomach is now dyspepsin. It is the duty of the medical profession to distinguish between the different causes of dyspepsia. the tools that enable the profession to do this are available.
Also, on examining some of the most common symptoms that our patients present, it is easy to find serious limitations of this approach.
Fever has a large number of causes in the tropics. Infecions dominate the list. However, infections are so numerous that this knownowledge is of limited value, as the different infectiions require different approaches and therapies.
Basing diagnosis on the clinical complex is thus complex and unreliable. Are doctors convinced of this complexity of causes in practice? if they were, there would be put in place a certain expectation of effort in sorting out in a scientific manner the different diseases.
Organisation of investigations
In addition to the organisation of investigations by symptom-sign, there is also a good bit of agreement on establishing panels of necessary investigations for certain groups of patients. The extent of this agreement may be debated. However, where public awareness is keen and the level of science in the society strong, it is not now regarded as entirely left to the attending physician to decide on such determinants of care. the reason for this is that when the investigations are not carried out, diagnosis is missed and the patient is the worse for it. The question then is, are we going to suppress the practice of good medicine because our people are not aware of the benefits of its best affordable facets? Do we have a right to do this? I do not think that the medical profession has such a right. On the other hand, what happens if the people cannot afford such facilities? The question of poverty must be addressed as a serious health and social issue. I have found it quite unhelpful to try to separate medical and social or poverty issues in health and disease. Much of the pathology that one sees is bound to poverty. My view is that if poverty so strongly affects health, then it is the duty of the medical profession to participate in arranging the economy to the b est advantage of population health. If the people do not survive or they are deliberated by disease, the economy and all else cannot be of meaning. Also, whatever is available must be maximized in efficiency and spread. For example, a large proportion of the population suffers from anaenia. The means to assess the level of haemoglobin in the blood should be provided at the primary health care centre. The technology is simple and the price affordable. Without fear of contradiction, the degree of anaenia in the country calls for public health measures.
Stool examination
When the British doctors were here before the country became an independent nation, a part of every hospital emitted the recognizable smell of stool specimens used for microscopy for the diagnosis of enteric parasites. This was usually the laboratory or the microscopy portion of the out patient clinic. Noticeably, this smell has for many years disappeared. Have intestinal parasitic infections ceased to be a problem? No, they have not. In some rural communities intestinal parasites are almost universal. If that is so, what has the medical profession replaced stool microscopy with? This examination has not been replaced. The profession seems simply to have ignored the test and the parasites, leaving a sick population to battle to the extent (that they can against other diseases and infections. Some intestinal parasites such as hook worm and Schistosomemansoni cause severe disease.
What I say to my students and to you is, may your clinics smell of faeces’. The recent apparent solution to this problem is the mass deworming programme, which we shall shortly deal with under the heading of the alternative action brigade.
Chest x-ray
The clinical report on the patient with abdominal distension that I have referred to serves to illustrate the failure to use chest x-ray when it is indicated. Because the patient presented with a markedly distended abdomen, the doctor believed’ that the patient had ascites from a liver disease. The liver function tests did not show abnormalities as that were helpful. After some time in the hospital the patient was reported to have a cough. The doctor then ordered a chest x-ray which showed miary tuberculosis. It is difficult to comment on this case if one was not going to be critical, except to add that the haemoglobin had not been determined. I wonder how many know that the most common cause of serious anaemia in Nigerian adults is tuberculosis. muliary tuberculosis is a desperate disease. Treatment fails if it is not applied promptly. The attending doctor in this case did not state whether his stated belief was on the holy koran, bible, or other book of faith. Medicine seeks evidence which must be provided for the benefit of the patient.
Haemoglobin electrophoresis
The abnormal haemoglobins S and C are common in the African population. The prevalence of S that causes severe disease and death is generally high. For example, in Garki, Kano state, the prevelance rises from 23 percent in the newborn to 29 percent at five years, after which there is further change. Also, homozygous S and the combination of S and C wreaks havoc in pregnancy. How is it possible that medicine in Nigeria could remain today indifferent to the haemoglobin type of children mid pregnant women? Haemoglobin type determination is required of a woman in her first pregnancy at her first visit to a care clinic. The great majority of Nigerian women have not had this test, and the consequences reflect on the high maternal mortality rate and heavy morbidity that Nigeria is notorious for, despite the monitions and example of the likes of Dr. Abubakar Imam.
HIV infection test
It is not possible to make a diagnosis of infection by the human immune deficiency virus (HIV) without laboratory investigation. The standard screening test for this infection is that applying the enzyme-linked imuinio-sorbent assay (ELI SA) technique, and confirmation is by the western blot method. For many years after acquiring the infection, the disease does not manifest, and there is evidence now that during the preclinical phase of the infection, certain drug treatment is effective in delaying the onset of the disease or death. A proper diagnosis is therefore necessary. Also, blood transfusion without screening for HIV poses a serious threat of transmitting infection. Some countries have considerable genetic HIV infection so serious that they have enacted legislation in making it legal. The penalty in Russia, for example, is from two to twelve years imprisonment, depending on the number of patients infected. Compare this to the Nigerian scene.
In the mid 1980s international agencies donated ELISA equipment and reagents for HIV testing to the country. Incredibly, one or two of the ELISA machines ended up in laboratories away from hospitals. For a number of years the doctors in such towns continued to transfuse unscreened blood to patients. They apparently felt absolved of responsibility by simply marking on ihe blood unit ‘not screened for HIV. Similarly, in subsequent years, donated ELISA machines have ended up with the body of the machine at one hospital, and .the washer at another, a long distance from the body. It is not possible to use the machine without the washer. These occurrences are so improbable that I am not able to discuss them. The medical profession must take the initiative in protecting the health of the population. Rather. it took the intervention of the political appointee, the minister of health, to make it mandatory for doctors to screen blood for transfusion.
Currently, there has been despair of the use of the ELISA machine for lily testing in Nigeria, which is probably the only counter’ in which such despair has occurred. Most of the tests that are in use have not been licensed for use in their countries of manufacture. I have discussed this problem with the heads of the national progranimes, and they are satisfied that these tests give correct results in their experience. The medical profession must have evidence of this. One worry regarding accepting substandard or nonstandard tests is that such an approach may also accommodate substandard dinaenosms, preventive measures and treatment. The recent establishment of an AIDS reference laboratory at the National Institute of Medical Research in Yaba, Lagos, is encouraging. However, how will that laboratory serve the nation’? What is to be referred, the patient or serum, and how’?. Early in my career, I realized that when a public figure or political personality is invited with fanfare to commission a laboratory equipment, there is likely to have been a degree of misunderstanding of science. If that has been installed in Yaba is an EL1SA machine and the western blot technique, then the country needs many more Yabas. The HIV/AIDS pandemic is a serious problem.
Having spoken at such length on HIV/AIDS, I am sure that a number of people in the audience would expect me to mention Abalaka. Abalaka is the medical doctor who has claimed to have produced certain controversial and unproven forms of cure for AIDS. Well, I have done so now. With the recent experience with Pfizer, I feel certain that the people of Kano are not about to blindkly take anyone’s medicine or injection in controversial circumstances. Pfizer in recent years exhibited on the Kano populatiion a certain vaccine that the company did not reveal to be experimental. The vaccine resulted in the maiming and death of a number of children.
Investigation of some common diseases
Although there is a certain risk in belabouring what people already’ know, we shall take the example of diagnosis in malaria and mention one or two other common diseases to illustrate the importance of the best evidence of arriving at a diagnosis. This chances the approving the approach a little bit from starting with symptoms and as we have done. I do let my patients say to me that they have hypertension or diabetes mellittus because these are measurable chronic disorders that they ought to have good knowledge of. On the other hand, I do not like them telling me that they have malaria or typhoid when they have a fever cancer and feel unwell .
Malaria
The three common parasitic infections shall serve as examples of common diseases which the means of establishing a definite diagnosis is available and affordable. How is malaria diagnosed without a blood smear? It cannot be so diagnosed with confidence. Malaria kills millions of children in Africa yearly. It contributes significantly to morbidity and some mortality regions of Africa. In fact, in the three minutes that I shall discuss the malaria problem and its diagnosis fifteen people would have died from the disease. There appears to be serious defects in the information level regarding this common fever disease. When I have an opportunity, I say to groups of doctors or medical students, suppose someone arrives from home and informs you that your favourite uncle died at dawn and that he died of malaria. Then I put the question, what would be your reaction? There is no need to repeat here the responses that I received. The true position is that you can say to the doctor that he is not right. There is no chance of your uncle in Dutsen Ma, Damaturu or Abonema dying from malaria. Nigeria infants and young children up to the age of five die of malaria. Beyond that age, death from malaria is not likely. Certainly, it does not happen in adult males, as immunity developed over the years does not permit of such severity of the disease as to become fatal. It may cause severe mortality in one’s pregnanct aunt, and contribute to death through animal because in pregnancy immunity to malaria diminishes.
There is a necessity to diagnose malaria. Can one maintain this point of view in the face of such sidespread and severe infection and the availability of blood smear microscopy shows the level of parasitomia. This enables the attending doctor to decide whether or not malaria infection is is responsible for the seventy of symptoms in the patient, or there is a need to investigate for other diseases. The answer, therefore is yes, there is a need to examine the blood for this blood parasite, make a clear diagnosis, and determine the severity of infection.
To be continued next week