The Curious Case of the Boy with "Missing Intestine": Are we Dealing with a Medical Communication Issue?

In recent times, the media in Nigeria has been inundated with the news of a boy whose intestine mysteriously disappeared at a hospital, with allegations of foul play. The recent visit of the Governor of Lagos State to check on the health of the boy has, once again, brought the story to the limelight.

The details of the case are not available to the public, and it would be speculative to talk about what happened. However, it is apparent that there is a communication problem.  How could the intestine be "missing"? This word may have been used at some point in communicating the health status of the patient, and it is now driving the sensations around this story to the detriment of the patient's confidentiality.

How we communicate medical conditions or findings is as important as the information itself, especially when we are dealing with the lay public. Patients and their families deserve information and explanation, communicated in the language and nuances they understand, and in an ambience that accommodates feedback and clarification. Medical practitioners must be intentional about ensuring that patients and their relations understand what diseases or injuries are present, the planned course of action concerning further investigation (where required), treatment options, expected outcomes (including the possibility of failure), general and specific risks, and complications. There cannot be truly informed consent if these elements and other relevant ones (depending on particular patients, their families, and their contexts) are not in the ingredients.

Effective communication, especially in medical practice, is not measured merely by the volume of information provided to patients or their next of kin. Rather, it is determined by the extent to which they fully understand what is being transmitted to them. The power imbalance between the healthcare provider and the patient often comes into play in their interactions. The medical doctor must recognise the dynamics and put the patient and their relations at ease by assuring and demonstrating the primacy of their preferences in any medical decisions. This disposition must be reinforced at every opportunity because health facilities exist basically to care for people, and these are patients and their communities.

I hope the Lagos State government will undertake a thorough investigation as indicated and get to the root of this odd case of the "missing intestine" in the circumstance. However, it may well be that miscommunication and misinformation may have misrepresented the misadventure of medical interventions in this patient.

Meanwhile, all hands must be on deck to save the life of this boy. The commitment of the Lagos government is commendable.

Complicity of Professionals-2

About 10 years ago, I wrote a short note on the "Complicity of Professionals-1". After over a decade, the status quo remains the same. No, the situation has worsened!

Professionals, especially in Africa, could do more to promote good governance and development in their different contexts across the region. They possess comparable knowledge and skills to other practitioners in any part of the world. So, the puzzling question is: Why is there such a slow pace (if any) in development in these parts of the world, where they have professionals in different fields of endeavour, who could trigger and sustain modern development through their innovation and leadership of the various sectors? Interestingly, in a significant number of countries, professionals head their respective ministries, departments, and agencies: lawyers are usually in charge of the Ministry of Justice and Office of Attorney General; finance and account experts oversee the Ministry of Finance and relevant departments; medical doctors superintend the Ministry of Health; and a similar pattern is seen in other ministries. So, why are we not making appreciable progress in Africa?

I have identified a lack of courage as a major reason. The lack of courage to stand firmly on professional protocols irrespective of the pressure to compromise standards. The lack of courage to speak the truth to power based on conviction; the lack of courage to risk the power and perks of office by upholding integrity and transparency; the lack of courage to resign when it is no longer tenable to keep a position without the opportunity to deliver on the values that enhance the quality of life of the people served; and the lack of courage to shun parochial interests.

Africa, and indeed the rest of the world, can make more progress if citizens, including professionals, summon more courage to confront corruption, first by living by example and subsequently propagating this lifestyle both upstream and downstream of their cycle of influence, interactions, and transactions.  We cannot afford to retell this story every decade. The knowledge, skills, and tools needed to advance humanity are more at our disposal in this era than in any other period in our history. What are we doing with this opportunity? 

The Calm Before the Storm. Then COVID-19 Pandemic. And post-COVID-19?

As of 2018, I was neck-deep in an international forensic mission crisscrossing different parts of the world in an assignment that held deep meaning to my heart in the dignified management of the dead, including forensic human identification. Generally, there was some stability in the air. Travelling was normal: arrive at the airports, do regular security screening and check-in, and take off! Then arrive and disembark. And repeat. Crowded terminals were a usual feature of ports of entry and were expected. Life as we knew it was pretty regular, with its thrills and downsides. The dynamics of operations added elements of surprise and unforeseen circumstances.

2019 came by as fast as it could, and towards the end of the year, news about some unusual illness initially limited to a certain part of the world filtered in. Regular folks paid little attention to such a "sectional" event, and it appeared to be of concern mainly to international bodies or agencies that track diseases and their evaluation. In any case, no one was really certain about the significance of such little incidents of "unusual" diseases. However, the talking points grew louder towards the end of 2019 and the first quarter of 2020, when the global alarm was sounded about a disease of significance tagged COVID-19. Eventually, in March 2020, the COVID-19 pandemic was declared. Then life took a different trajectory, and everything we called "normal" turned upside down.

I was drawn into the deep fight against COVID-19 with my appointment as Chair of the institutional task force against the pandemic. It was a "life and death" assignment. We were fighting a disease that had never existed in humans before. There was no established manual to handle the global outreach, and humanity as a whole was making up protocols as we faced the existential challenges of a ruthless malady. There was confusion about everything, even from high places of advancement. Facemasks work. Facemasks do not work. Drinking bleach is effective! Bleaching agents are harmful. There was a cacophony of voices, and the pandemic caused divisions along political and socioeconomic fault lines. People died in the murkiness of narratives and the lack of coherent leadership. People died from the fear induced by the disease. People died from mismanagement of even ordinary medical conditions because of the shadow of COVID-19. Millions died from the disease and related medical and psychosocial complications brought about by the pandemic. We may never know the exact death toll from COVID-19, but it was a disease of the century that changed everything we regarded as "normal". 

2020 to the early part of 2022 was a period of "to be or not to be". I devoted my entire life and career to fighting COVID-19 as the head of the task force at our institution and knew the risk it posed to my life. However, it was a fight that must be fought if we are to survive. We usually prevail when we pull together and confront our common adversary, of which COVID-19 is unmistakably one. Sadly, so many lives were often needlessly lost, families were torn apart, communities were shattered, and our way of life was disrupted for about two years. We woke up every day with the thought and disposition to survive each day. The long-term plan was simply to stay alive. We abandoned the things that brought us together so that we could live. And amid the whole conundrum, we learned to come together by staying away from one another. Online meetings and platforms sprang up, and remote work and relationships became mainstream.

Now, in 2023, my mind is gradually getting back to "factory reset". I still have a nagging question: Is COVID-19 over? There are still echoes of the pandemic and its metamorphoses breaking out from time to time, and we cannot afford to be completely at ease. However, we need to know what risks we have as we gradually return to any semblance of "normal". Should we prepare for further dislocation of our new "steady state"? I don't know, but one commitment I would like to make is to return to my engagement with you on this blog. And I'm optimistic it will be more regular than in past years!

Forensic Investigation of alleged killings of Protesters in Nigeria

The past few days in the country have been one of the most tensed and uncertain in living memory. The alleged violent disruption of ongoing protests against police brutality and related issues by the security forces, who allegedly shot at the protesters, especially in Lagos, has generated both national and international furore and condemnation. The news media is awash with different accounts of the incidents, and some protesters were reportedly killed in other parts of the country. And tension is rising by the day. 

The different accounts in social media, including apparent misinformation and possibly fake news, have complicated the situation. People need to know what happened. Did the protesters suffer injuries, either non-fatal or fatal, from the alleged shooting by the army, as suspected? How many died? Where are the bodies of deceased persons? Has post mortem (PM) examination been carried out in line with existing Death Investigation Law of the jurisdiction? What are the PM findings? Are the findings able to clarify the mechanism of injury causation and support some reconstruction of the incidents? Are there forensic facilities, at the national or state levels, with requisite modern tools and expertise to undertake these tasks? Is the world ever going to know the facts of the alleged killings of peaceful protesters in some parts of the country?

In a globe where it is becoming increasingly difficult to separate facts from fiction, credible evidence is required, and forensic investigation is a veritable means of achieving it. The world needs factual answers on the alleged shooting of peaceful protesters at Lekki in Lagos. The relevant authorities need to follow through on this pathway. However, it is doubtful this tract will lead to any credible and definitive answers given the constricted forensic content.  It underscores the value of investing in forensic capacity. Facts!

Police Brutality in Nigeria: Violence is NOT the Answer to Violence

Changing Trends

The protests against police brutality, which started early October 2020, have gained national and international recognition and traction, and there are little signs the struggle is abating. In recent times, there are reports of violence against fellow citizens going about their businesses. Some images of alleged damage to property, especially vehicles of individuals, and government agencies, are on social media. There are also reports, in a few places, of the threat of violence against ordinary people caught up in the milieu. 

Fundamentals

In a democratic society, there should be freedom of expression, and people should be able to protest against any policies or programmes that are not acceptable. Such civil expression is a hallmark of real democracy which must be upheld at all times. Protesters should be protected and allowed the environment to express their views and disapproval of any situation, such as in the ongoing "ENDSARS protests", the signature for an end to all forms of police brutality and corruption in the country.  It is equally essential that the demonstrations are peaceful and devoid of harassment and violence against members of the public or government officials or property.

Dynamics

So far, most of these protests across the nation are peaceful and should remain so. However, there is an allegation that some elements may have infiltrated the demonstrations to foment trouble and discredit the struggle with instances of alleged armed thugs attacking the protesters and other members of the public. Concerned authorities will need to support the peaceful protests by working with the organisers of this genuine struggle in fishing out bad actors that are stirring up trouble and may attempt to hijack the process. The Nigerian youth want to have a future. They need a tomorrow where they can move about freely without hindrance, harassment and brutality; where there will be equal opportunity to grow and develop; and a future where there won't be any need to be connected to the politicians and the corridors of power before they could make a living. The youth are demanding for merit, equity and justice.

Insight

Therefore, "ENDSARS protest" is a symbol of a more profound struggle for survival and not a call to violence. Whether on the protesters' or the government's side, any resort to violence will be counterproductive as it'll set the entire process and whole nation backwards. The toll on human lives and property will be catastrophic. 

Violence is NOT the answer. #ProtestsNotViolence.

Police Brutality in Nigeria: SARS to SWAT; What's in a Name?

What's the focus? 

When the country announced the disbandment of the ill-famed Special Anti-Robbery Squad (SARS) of the Police, it might have conveyed the impression that the problem was with the name. The acronym, SARS, may conjure up distressing imagery in the minds of Nigerians, especially those who had received a raw deal in the hands of the officers from this unit. No one could argue against the need for a special anti-robbery squad to combat the incessant armed robbery attacks and other violent crimes in the country. It's trite to state the police are for law enforcement in maintaining law and order in the society, and it's not in question that society needs a functional and effective police system.

The sudden announcement of the formation of another special unit, the Special Weapons and Tactics (SWAT) by the police authorities, within a short time, may have betrayed some misunderstanding of the whole essence of the protest against police brutality. SARS is merely a metaphor for the abuses citizens suffer in the hands of the police. SARS is emblematic of the lack of police accountability to the people and the pervasive acts of impunity. SARS is the point of contact in registering grievances against the mode of operation of the police in the country. The problem is not in the name; the issue is in what the word represents. 

What's needed?

Accountability matrix. Citizens can no longer rely on the goodwill of some police officers to always act in the interest of common good at all times. People want to see credible and transparent mechanisms of holding every police officer, who may wish to operate outside of the norm, to account at all times in all places. A verifiable means of registering complaints of misconduct against the police and means of tracking action taken by the concerned authorities and eventual redress will be a significant step forward. 

Generally, people don't trust the police anymore. Officers of the law must begin to conduct themselves in such a manner that the long process of restoring the confidence of citizens in the police could commence. Therefore, building trust is a top priority.

SARS to SWAT tone-deaf?

It appears the loud cries from the protests against police brutality may not be reaching home. Announcing the formation of another particular police unit, the SWAT, would in the minds of most Nigerian naturally translate to another licence to high handedness by another police "elite" group.  To ordinary citizens, "elite" means being above the law, abuse of power and corruption, and to operate with impunity. And creating such similar units within a couple of days following the disbandment of SARS and while protests against police brutality are still ongoing appears insensitive and tone-deaf. A good deal of time and commitment should have been invested in building trust through the practical demonstration of respect for civil rule by the police. 

Disbandment of SARS has not ended police brutality. It is instructive to know that citizens are still experiencing police high-handedness and brutality amid ongoing protests despite the ban on SARS. In every police officer, there is a "SARS" waiting for the opportunity to unleash on defenceless citizens. Wouldn't a better approach be first to announce some concrete, credible and acceptable measures at redressing the brutality and injustice meted out to people by SARS units in particular, and the police in general, and then engage stakeholders, including the civil society on the best practices in policing, including real-time monitoring of subsequent police actions and interaction with the populace?

What to do?

There are no easy answers to the problem bedevilling the police and policing in Nigeria. The police need to be transparent about their recruitment processes of the right profile, merit-based promotion and procedures guided by standards. There is an urgent need to embrace the theory and practice of community policy in gaining the trust of the people. Officers, including their superiors, who have been accused of abusing their powers and other forms of corruption, should be thoroughly investigated by an independent investigative panel. Those indicted should be prosecuted per the law. There should be a clear statement and official policy, backed by visible actions, that it is no longer business as usual; that police brutality and corruption cannot be tolerated anymore. The police should also be supported and provided with the necessary tools, current knowledge and skills required for the difficult work of policing in the contemporary world.

Police Brutality in Nigeria: Officers under the Influence

Context

It's hard to be a police officer anywhere in the world, and I would add, frustrating to be one in Nigeria. With inadequate equipment and poor condition of service, officers grumble openly about their plight and are quick to project their anger and frustration on the hapless citizens. And tackling armed robbery, armed banditry and other forms of violent crimes in the country, often comes at a grim cost: the death of officers in uniform. The nation shrugs it off as one of those "unfortunate" incidents and moves on, but it's a complete loss and tragedy for their loved ones. And the gory tales, of their families and dependents, of apparent abandonment by the concerned authorities and dismal compensation, echo the misery of life being nasty, brutish and short for an ordinary officer.

Contrary to standard procedure, officers are not usually provided necessary debriefing, including a psychological evaluation, after engaging in operations that result in fatalities, including the loss of their colleagues in action. The prevailing culture sees it as a sign of weakness to ask for help regarding any psychological disturbances or mental health issues. Everyone is expected to "man up" and move on. Of course, some officers tend "man up." with alcohol, drugs and other behaviours that put them and the general populace at risk. There are police protocols, including handling of traumatic events, in line with standard practices. In Nigeria, these should not only exist in the text but also, more importantly, is implemented and appraised. Appropriate briefing and debriefing sessions following police operations should be a standard procedure, and availability of adequate mental health assessment and support is imperative. 

Forensic Toxicology

It is not uncommon to see police officers, especially those in the select units like the now disbanded SARS, with bloodshot eyes and breath that is retching with alcohol. It is a piece of common knowledge that officers abuse alcohol and other drugs, even while on duty and in the open! It is easy, and justifiable so, to focus on such odious and unprofessional acts, because the cost of miscalculation or impaired judgment on the part of a law officer is tragic. However, the brutality unleashed on citizens by the police may not be unconnected with their state of mind and impaired capacity to make a sound decision in the various circumstances.

Is there an alcohol and drug testing protocol in the Nigeria Police, including pre-recruitment and random in-service testing? No. My interaction with police officers indicates such functional protocol does not exist. There is no robust government forensic toxicology testing in the country, even to support routine forensic death investigation and clinical forensic caseloads, in the course of the police investigation. It is not a piece of evidence that will survive any challenge to say those police officers appear drunk while at work. There must be a system in place to document and check abuse of alcohol and drugs by officers of the law, who are meant to uphold law and order. Evidence is required—forensic toxicology beckons.  

Action

The police operating under the influence of alcohol or drugs is both a red flag and a red line. Therefore, the process of accountability needs to dive deeper into all the existing police procedures and apply necessary measures.  And it must also include sufficient emphasis on the officers and their overall state of health, be it physical, mental and social.