Suppositions and investigative medicine (II)
By Ed. B.ATTAH
Continued from last week
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 among pregnant women in the malarial regions of Africa. In fact, in the three minutes that I shall unfortunately discuss the malaria problem and its diagnosis fifteen people would have died from the disease. There appears to be still 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 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 Dutsin Ma, Damaturu or Abonema dying from malaria. Nigerian 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 pregnant 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 widespread 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 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.
Also there appears to be a certain fascination with cerebral malaria as a condition for diagnosing potentially fatal infection in children. This may be because of the drama of the associated convulsions. In fact cerebral malaria is only one of the modes of death in this disease. The clinical fixation to convulsions contributes to missing severe and potentially fatal malaria. The clinical diagnosis of potentially fatal malaria remains low as shown in autopsy studies. To wait for convulsion in malaria is to wait for the child to die. Convulsion in malaria may be looked upon as the sign of a dead child that has been brought to the clinic for certification.
Even from the early description of severe malaria, other expressions of severe infection were recognized. These are algid malaria in which the patient is prostrate from overwhelming parasitaemia; cholereic malaria in which diarrhoea expresses the infection and black water fever in which haemoglobinuria is responsible for dark brown or black urine. To this has been added renal shut down from American experience in Vietnam. Unless blood smear examination is carried out, the diagnosis is missed. Among these, black water fever seems to be mostly seen in severe sepsis in Nigerian children. Diarrhoeal expression of malaria is more common than is recognized. Blood smear examination would save many a child. In the children that tend to have this manifestation, the diarrhoea precedes pyrexia. Malaria must be diagnosed and treated early.
Regarding the arming of drug peddlers and other vendors with antimalarial drugs, we shall shortly discuss the matter a little further when we come to talk about the alternative action brigade.
Hookworm disease, Schistosomiasis and typhoid
I shall only briefly deal with the diagnosis of these common infections. Hookworm infestation can simply be diagnosed by stool microscopy. Without stool microscopy, the patient suffers or is exposed to the alternative action brigade. In schistomiasis, the doctor must know the limitation of the test that is applied. In S. haematobium, regarding whole bladder digestion at autopsy as yielding one hundred percent diagnosis, cystoscopic biopsy yields two thirds and urine microscopy only one third. In other words, Using only urine microscopy in a population of an endemic area will only’ diagnose one third of the patients that harbour the parasite. Surely, to wait for the dramatic symptom of terminal haematura is to aim at the obvious. The contribution of microscopy or a doctor in such a circumstance is only of passing interest.
Laboratory overdiagnosis of typhoid has been with us since about 1994. The tile tests are simple to perfom provided that the technologist follows the instructions of the manufacturer. Unfortunately, this is not the case and there has been a raging laboratory epidemic of typhoid diagnosis over the years. The test remains positive no matter what treatment is given. Meanwhile, the patient would have recovered from whatever fever he had. This matter cannot be dismissed because it beclouds the correct diagnosis and creates much anxiety and distress in families. It results in the administration of wrong treatment and lowers the credibility of laboratory reports generally. Recently an engineer informed me gravely that he was recovering from malaria-typhod. In fact, this diagnosis had been given to him by his doctor. Interestingly, when I told this story to a group of educated people, hardly anyone showed any surprise. this indicates a sad state of professional practice.
Common diseases that are ignored
Some common diseases are simply’ not diagnosed any more. Some of these are serious diseases that cause considerable morbidity and mortality, and are endemic, epidemic, or both. Because of time, it is not possible to discuss the investigative findings that help in establishing their diagnosis in this lecture. The off-hand tendency has been to return a diagnosis of malaria or typhoid in the ones that cause fever. In 1999 and 2000 there was an epidemic of a haemorrhagic fever in the south east of the country, affecting to my knowledge Cross River, Akwa lbom and probably Rivers states. As far as 1 know, that epidemic elicited no comment from any medical source. It presented in the individual as a lever, persistent splitting-headache syndrome. The three deaths that I observed occurred rapidly from the onset of symptoms and terminated with the vomiting of coffee grounds.
Quality control and clinical audit
Quality control and clinical audit have been standard practice globally for so long that they would only have been mentioned here merely for completion of the discussion. Unfortunately, hardly any hospital in Nigeria practices quality assurance in any meaningful form. This is an unacceptable situation. Without these tools, practice is blind and patients do not know what they are getting. Quality assurance activities cost money. However, without them, standards of practice fall. Some level of quality assurance activity is required to avoid the falling of standards and endangering the patient. These remarks cover all aspects of diagnostic services and blood transfusion which is in many an instance a disservice.
Loss of control of clinical laboratories
The professional agitations of the late 1970s and early 1980s brought in their wake, demands by the members of the Institute of Medical Laboratory Technologists to operate independently of medical supervision.The claim to have been acceded to by the military government, whereby, private laboratories set up by laboratory scientists or technologists do not have any clinical supervision. The faculty of pathology of the Nigerian Postgraduate Medical College did everything possible to show to government that operating clinical laboratories without clinical supervision was not in the best interest of patients or the health services. Memoranda were submitted and representations were made to the minister of health in the interest of the health services. In 1989, at a chance discussion with the minister of health, I found that a decree on the issue was in the making. The minister also informed me that no representation from pathologists had been brought to his attention. There was no lack of submission by technologists. I tried to get the Association of Pathologists to take urgent action on the matter. I am not aware that much action was taken. Thus there has been loss of control of standards and clinical determinants in the private laboratories, a situation that may need attention in the future. I understand that even in some federal government hospitals, the pathologists are not in charge of the laboratories.
Application of new techniques
The larger hospitals not infrequently rush to employ techniques and treatments that are not of proven efficacy. These may involve the patient in expenses that do not bring value, or have unwholesome or questionable effects on the patient’s health or safety. That raises the question, when is a new diagnostic method or technique considered established? The answer is sought in two interrelated spheres of professional activity, namely, medical science and medical practice. While the science analyses the published data on the method for possible flaws, the circumspect practitioner shows caution in taking up any new reported ancillary methods. On the whole, techniques and diagnostic methods are relatively more or less established, depending on the total experience of the medical community. Examples abound of tests and methods that were considered diagnostic but turned out in the end to be unhelpful or even misleading. These include serum carcinoembryonic antigen (CEA) levels as a method for detecting recurrent carcinoma of the colon.”’
Testing of public health measures
The testing of public health measures is essential in deciding the best course for any population. In the case of Nigeria in which much of the population is not familiar with the terms or measures that we propose, it is mandatory to ensure that we do not abuse the people by coercing them into measures that in the end prove unhelpful or even harmful. The profession cannot forget that it spent much time and energy persuading the African population to give babies artificial feeds and animal milk formulas. The disaster that followed was colossal, by way of the death of millions of children through wrong formulation and infective diarrhoea, needing international intervention. Currently there are posters supposed to campaign against cigarette smoking, but which state that second-hand smoking is not healthy. In these days of mass ‘tokunbo’, this seems to suggest that first-hand smoking is healthy. I am quite sure that this is not what the people putting up the posters mean, but it could possibly be what the designers intended, as the design is suspiciously reminiscent of a well known cigarrette brand, complete with mounted horses.
Awareness of tests by the profession
The matter of awareness of technical advances and applicable tests by doctors is not to be taken lightly. Nigeria have left itself behind for so many years in the advances and applications of technology in the world , there is a great deficiency in medical awareness of applicable and sustainable technolgies that have simplified and made more accurate the practice of medicine. for example, incredible as it may sound, one teaching hospital received a donated US machine and left it in the container for six years. As another example, the last time that urine sugar was used in monitoring diabetes mellitus was many years ago, except in Nigeria where the great majority of’ doctors still apply this test while blood sugar could just as easily be used. The advantages of control using blood sugar do not seem to have gone down to the clinics. Many do not know about the test for prostate specific antigen which specifically diagnoses cancer of the prostate. Or of the attraction of the bedside laboratory. These are small, efficient analysis machines. They are placed in patient stations such as the wards and the intensive care unit. With daily priming and standardization, they can be used by the clinical practitioner, effectively replacing the technologist or pathologist in determining the common parameters of’ patient care.
As things are, I suspect that in attempting to rebuild or equip the laboratories and imaging units, it will be found necessary to have people go abroad once again, so that practical knowledge can be acquired. It sounds like starting over again, but it seems to be a necessity if we are to move forward. In the country, the profession must embark on continuing education as the technologically advanced countries have done. This will take some study and persuasion, but I see that it is unavoidable. It may be tied onto the maintenance of certification process for effectiveness.
The alternative action brigade
Or the mass deworming approach
I use the expression, “The alternative action brigade” to describe the approach to health care that is typified by the mass deworming of the population. In attitude this approach states, ‘no more investigation for worms in human, no more diagnosis, just treat everyone’. By the definitions and explanations that we started with, this approach qualifies as an alternative to scientific medicine. It adopts proven scientific therapies and applies it massively and blindly, apparently satisfied that the treatment does no harm. In the field, one observes that the doctor and nurse and their families do not take the deworming medicine. Nor do they administer them to people of their cadre. This portrays an element of discrimination not based on medical evidence. So, the mass deworming exercise is in practice not universal. There are circumstances in which mass administration of medicine is appropriate and scientific. Examples are in anticipation of epidemic meningitis outbreak in the dry northern parts of West Africa, and in nearly year-round Samulium bites in river blindness regions of the wet southern forests. In these there is scientific evidence of universal bite, and only the unwise health worker exempts himself, his family or friends. In the case of arming medicine peddlers with antimalarials, great care must be taken in monitoring the procedure.
Lack of professional involvement in decision making.
An important aspect of the alternative action brigade movement is the lack of involvement of the medical profession in the decision making process. I use this opportunity to say to Nigerian doctors that the ministry of health, even if headed by a medical doctor, with doctors as the professional heads and permanent secretaries, does not represent the medical profession. The ministry is the executive arm of the government. It is the expected duty of the medical profession to draw attention to the areas of national heahh that require attention, and initiate activities that result in government policy and action. Unfortunately, it seems that the many years of military opposition to the medical profession in Nigeria has wrought great havoc to the medical psyche, and it is taking some time to recover.
Society role in medical investigation
Informed society has an influence on the type, extent and quality of medical testing. for example, society legislates on the medical investigation of an unexpected death. In the living an example is Japan where cancer of the stomach has its highest incidence. A combination of endoscopy and double contrast barium radiological studies has tamed that cancer. Similarly in the United Kingdom and U.S.A. where breast cancer manifests its highest incidence, mammography and fine needle aspiration biopsy have contributed immensely to the control of that cancer. In Canada, cervical cytology has made death from cervical cancer rare. In Japan where cancer of the breast is notably uncommon, mammography is employed in controlling even the small numbers of that disease in the population. In all cases, the role of the society is spearheaded by the medical profession. An example of achieving such programme in Nigeria would be pelvic assessment of women using US to minimize obstruction of labour during childbirth.
Continued from page 8
Another would be cervical cytology screening to prevent infiltrative cancer of the cervix.
Premarital medical tests, confidentiality, consent and informed clientele
The fact that some medical tests have been popularly adopted means that the informed portion of the population suppositions and superstition, and believes that social action may have a salutary impact on the relevant diseases. One such test is the typing of heamoglobin. The distress that goes with raising a sickler child has made some groups, noticeably religious groups advise, prescribe or require haemoglobin typing before marriage. Another is testing for HIV infection. It is possibly supposed that there is little or no distress in dissuading or stopping loving couples from marrying. Also, the circumstances in which the results of such tests are revealed deserve consideration. On the other hand, one finds surgeons demanding the HIV test as a precondition for performing even emergency surgery. Such doctors do not know what to do with such information, as only the unwise treats any human fluid or tissue as uninfected. Such practice amounts to superstition of a sort. I have seen an animal farm in which the foreign managers compel the Nigerian workers to undergo periodic HIV tests.
Considering the level of falsification of results that we have witnessed with haemoglobin type testing, those that want to embark on premarital HIV tests must think properly on what they, are doing. As I have stated, the tendency is most seen in religious groups, presumably because they conduct most marriages. On the other hand, some religious groups want to hear nothing at all about HIV/AIDS. To me, this contradiction emphasizes the need for medical leadership on such matters of public health importance.
Manpower in investigative medicine
The provision of personnel in the hospital laboratories is revealing with respect to the expected work output. For instance in northern Nigeria in 1954-55-56, the only category of laboratory professionals provided for were laboratory superintendents. Only two positions were established in the entire ministry of health. There were at that time also only two positions of radiographers in the northern Nigeria ministry of health. One supposes that there was little inclination to investigative medicine at the time. However, some of the numbers in the establishment might reflect the realities of the time. For instance, of the meagre 42 positions of nursing sisters, 10 positions were vacant, of 27 health superintendent posts, only 17 were occupied. This might have been because there were no qualified workers to fill the positions.
Has that situation changed over the years? There has certainly been an increase in the numbers, but relatively little change considering the needs of the health services. In Akwa lbom State where I now live in a population of about four million, there are in the health services 36 medical laboratory scientists, no pathologist, six radiographers and no radiologist. However, to place the picture in context, only 60% of the Nigerian population has access to health care. With respect to medical personnel in laboratories I have tried in vain to persuade the postgraduate medical colleges to certify laboratory physicians with diplomas after two years of an active training programme that prepares them to plan and manage laboratory services. All the governments of West Africa have expressed interest in such programmes and diplomas. However, some in the colleges think that longer periods of training are necessary. Meanwhile, the diagnostic services in many states are headed by people whose training and preparation cannot allow of efficient performance. Also, I find that hospitals and ministries of health do not know where to turn to for guidelines on staffing requirements for the diagnostic services. The laboratory medicine faculties of the colleges are in the best position along with the associations of pathologists to give such advice. To be able to fulfil that role, they must study the problem in a serious manner.
Conclusion
The system of medicine that we practice is based on science. It can only be sustained by scientific investigation, without which professional practice moves into the realm of suppositions or even superstition. In the presence of an informed, confident and functioning medical profession, the diagnostic services would be strengthened, streamlined and standardized, public health measures tested and proven for value, and patients diagnosed using the best evidence, and the most efficacious and efficient treatments used applying best practice parameters. It should be impossible for a foreign or native medical product manufacturer to foist experimental therapies on Nigerians. It is time for the profession to organise itself to carry out tests in all aspects of health care. Then, the quality of practice shall not continue to be poor or the population to suffer from bad medicine. No matter how brutalized the medical psyche has been, a certain portion of it must be preserved free of all diversions and encumbrances, so that it continues in- all circumstances to serve our people, and fulfil the ideals for which Dr. Abubakar Imam lived.
I thank you again for the honour done me, and for your patience.

Concluded
ATTAH is a medical practitioner