In the Nigerian socioreligious belief system, ‘something’ must kill man. That something is variegated and will include but not limited to: avoidable carnage on the highways, painful deaths from stray bullets fired by the police or armed robbers, from exhaustion on pension queues, strangulations and brutality in police detention, cudgelling fracas at political rallies and [s]elections, exsanguinations at the auxiliary nurse’s, African remote control, witchcraft and wizardry, drowning from leaky rickety boats, preventable diseases at the Tradomedical homes, and from human errors and nosocomial infections in the hospitals.

The journal Medicine reports a data from a John Hopkins University 2008 study showing that about one in four patients feel that their physicians sometimes expose them to unnecessary risks. Though we lack good statistics here but several anecdotes report deaths resulting from misadventure, negligence or mismanagement in our hospitals. Thousands of iatrogenic deaths go unrecorded each year and unknown numbers of patients are buried with medical mistakes. The odds of an iatrogenic death are 33,000 times greater than dying in an air mishap. This is astronomical, and a cause for concern. Nigeria has recorded a number of air crashes since aviation began but these are few and far between, and to start with many have never flew in their lives but had been in the hospital at one time or the other.

The renowned late medical researcher Dr Tom Chalmers, and Dr Phil Hammond, in their original essays, once asked why doctors kill more people than airline pilots. Dr Chalmers suggested a number of reasons for this apparently grim discrepancy: pilots are required to take time off for sleep; they have their skills tested every six months and are breathalyzed at random. Pilots are legally obliged to spend 16 hours a year in a simulator, proving their competence, but for doctors this is a costly waiver. In his harsh home run Dr Chalmers remarked: ‘If doctors died with their patients, they would take a great deal more care’.

Thanks Dr Chalmers. But that will only scratch the surface of this ad rem issue in medical practice in Nigeria today. If doctors, like captains, died with their patients Nigeria’s nay global medical landscape would be the parched, arid Sahara because, as Marie de Sevigne rightly observed, there is no person who is not dangerous for some one. We all make mistakes, but this is not making an alibi for malpractice, negligence and malice.

In Nigeria a myriad of interwoven factors will make the above assumptions too simplistic. Medical practice in Nigeria is a milk-and-water, pitiable, insipid and dangerous tale- both to the patient and the medical team. Under such a vacuous state, anything can happen. The archaic under funded hospital infrastructural system is the fattest ant in our health ointment. This is the root cause of our doctors’ bloodied gloves. During the last administration, some feeble attempt was made to ameliorate the decayed infrastructural shame in some selected teaching hospitals but truth is the volume of patients seen by these tertiary institutions is infinitesimally small compared to what obtains in the private sector. I once worked in an urban private hospital where we see a minimum of 250 patients each day. Doctors in Nigeria work under prehistoric hospital conditions, there are no proper diagnostic facilities and fake drugs are commonplace, My Pikin being the latest misadventure. Very few private hospitals have CT scan and fewer teaching hospitals routinely use MRI; fluoroscopy and fetal surgery are textbook stuffs in Nigeria of the 21^st century. Some elite private hospitals may provide some of these facilities but at exorbitant price beyond the reach of the common man. So doctors are forced to inadvertently ‘kill’ patients because their hands are tied, they have to do ‘something’ for the patient; they act too late or too early or wrongly. If the dark-goggled one’s announcement of the 1983 coup described our hospitals as mere consulting clinics, a sadder verdict awaits us 26 years after! Sans perhaps the visionary BRF administration in Lagos, other states are still in slumber in areas of provision and maintenance of modern health facilities. We read so much about their achievements on the newspaper pages but there is very little to show for it. A form of Marshall Plan in the health sector is highly desirable at this point. During the Babangida era, the so called Federal Assisted Mass Transit buses were deployed to good effect in the transport sector. A public private partnership in acquisition and maintenance of hospital equipments and facilities may well do the magic. In Lagos State public hospitals, what good PPP can do is already being witnessed and enjoyed. Extending same to the private subsector would be our biggest break from the past and would definitely assist both doctors and patients. The idea of mega hospitals is equally good but isn’t it better to start with numerous small but well equipped clinics funded by the government but managed by private hands? In truth, very few private hospitals can ever, by itself, acquire what it takes to deliver modern healthcare. 

The brain drain has been our albatross since the early 80s. This has left us with an overworked, exhausted and inexperienced manpower. In the Western hemisphere alone, more than 25000 Nigerian doctors there are, bettering the already enviable health delivery system in these climes. Our lack of manpower is renowned, and is one of the points amplified by the doctors in Lagos government hospitals during the last work-to-rule cum industrial action. Fatal medical errors happen not just because of lack of skill or knowledge; in fact errors can happen in ideal circumstances but the error rate will be greatly multiplied when the staff is overworked and overstressed. Put someone in an extremely stressful situation and even the most senior clinicians can lose the plot. So the mortality figure rises. That the Nigerian medical doctor has the skill and knowledge is not in doubt but he is hamstrung by conditions he never created. “I don’t think doctors are bad people”, said Dr Sandeep Jauhar, director of the heart failure programme at Long Island Jewish Medical Centre, “they are just working in a broken system”. This is much truer in Nigeria than US. Maintenance of good infrastructures like road, power supply, water provision; good condition of services and competitive wages, security of life and properties, and most importantly good governance may well be good  incentives to discourage would-be ‘Andrews’. The government should employ more doctors to lessen the pressure on the already thin doctor workforce in public hospitals. Expanding the residency training programme to accommodate more residents will ensure we have enough qualified hands at least in the teaching hospitals. The halo effect will be felt in the private hospital setting sooner than later.

Errors happen either because doctors do the wrong things right or do the right things wrong. Doctors can make the wrong diagnosis, miss a diagnosis, prescribe the wrong drug or flunk a procedure. A dream medical team working under an ideal environment can do worse, since one can not always get it right in medicine and idiopathic reactions are everyday facts of life in therapeutics, but these human errors are more when and where experience is limited. I did my internship in those days when a houseman is not allowed to give intravenous apresoline or ripen the cervix without supervision. Partly because of overwork [as a result of brain drain and others] for the underpaid consultant, some procedures are as a matter of necessity may be handled by inexperienced hands; the poor patient becoming a statistic in the next morbidity and mortality review. Proper medical auditing and case reviews would extend the frontiers of learning and reduce error rates. In the UK for instance, the distinguished surgeon [and health minister] Prof Darzi has developed a simulated operating theatre that teaches his team to manage common distractions and rare, life threatening emergencies. He has also introduced the use of black box in the theatres to assist the surgical team to play back proceedings especially when things went awry. What prevents us doing the same even if it is ordinary intra-op video recording? A protocol or well ordered algorithm conspicuously displayed, in for example the ER, is cheap and durable. It would assist doctors to come to quick good management decisions and help reduce the toll. Medical auditing should be made a standard in all hospitals and doctors and all members of staff encouraged to honestly report mishaps and near misses. That way our knowledge can be enriched and our health care system better.

Patients also ‘assist’ doctors to up the iatrogenic death figures by not asking probing questions. In the US for example, patients are encouraged to ask about a surgeon's training and success rates, query medication, insist on hand washing and ensure the nurse has read their ID bracelet. They can even refuse life-saving drugs and medical interventions. This may be a luxury in Nigeria where to consult a doctor takes hours of waiting and to get on the surgical list takes months of perambulations but then this approach do work. In Nigeria, the patients’ complacency has dampened medical litigation and advocacy which when done in the right atmosphere are good stimuli for a better management. For example, LUTH’s blood transfusion policy is much better after baby Eniola saga. American doctors, ever wary of litigations, take safety much more seriously and the patients join in. While it is true that legal options can force the best out of us yet heed must be paid to ‘ambush medicine’ where the doctor is more interested in protecting his skin. Expensive yet often unneeded investigations are ordered and doctors err on the side of omission rather than commission. Also not to be discountenanced is the Nigerian’s penchant for trying to reap where he never sowed. But the legal dictum res ipsa loquitur may be relied upon to come to the aid of the careful doctor who made genuine mistake. Also, honest and well intentioned advocacy may serve as a brake to rash medical decisions.

Finally, though acculturation and western influence are fast changing our values, yet I doubt if we have the Dr Harold Shipmans amongst our midst in Nigeria.

Robot  # 1 | 29.01.2009 02:37

In the Nigerian socioreligious belief system, ‘something’ must kill man. That something is variegated and will include but not limited to: avoidable carnage on the highways, painful deaths from stray bullets fired by the police or armed robbers, from exhaustion on pension queues, strangulations and brutality in police detention, cudgelling fracas at political rallies and elections, exsanguinations at the auxiliary nurse’s, African remote control, witchcraft and wizardry, drowning from leaky rickety boats, preventable diseases at the Tradomedical homes, and from human errors and nosocomial infections in the hospitals. The journal Medicine reports a data from a John Hopkins University 2008 study showing that about one in four patients feel that their physicians sometimes expose them to unnecessary risks. Though we lack good statistics here but several anecdotes report deaths resulting from misadventure, negligence or mismanagement in ou...Read the full article.

maikanodahiru  # 2 | 31.01.2009 14:33

Thanks for this article