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14 Oct 2017

Wrong Diagnosis: Nigeria's Silent Killer

Wrong diagnosis has been identified as the silent killer which has been quietly taking many lives in Nigeria and around the world.
File photo: A hospital ward
Her shrill voice pierced through the hall’s silence as nurses wrapped the body of her husband.

Coming in high spirits all the way from Sango, Ogun State, to see her ailing husband of over 15 years at a government-owned hospital at Ikeja, Lagos that wet Tuesday morning, the sight she met at the male ward wasn’t the type she had expected to behold.

Like a giant palm tree felled by the blade of a ruthless saw machine, Hannah collapsed to the hospital’s dusty ground on seeing her husband’s corpse. All across the lengthy and packed hospital ward, an air of sadness swept through.

Even though Hannah’s husband passed on that Tuesday morning, he had actually ‘died’ a long time before then – two years earlier in fact.

A victim of wrong diagnosis, he was transferred from one hospital to another with doctors giving different verdicts on the cause of his situation during the period. A source at the hospital the man eventually died, told our correspondent that he could have been alive today if not for the wrong diagnosis at the beginning of his health problem.

The source added, “Unfortunately, the man had cancer but he was being treated for pneumonia, going by what was written in the referral note his people brought,” the source said.

“Maybe because the symptoms are somehow similar, they never knew it was cancer that had even reached stage four. We were able to discover this after carrying out series of tests on him. But by then, it was too late to save him and it seems they had spent all they had.”

After managing to summon some courage, the victim’s widow, Hannah, told our correspondent that her late husband spent his last days in severe pains, paying for an error that was no fault of his. According to her, misdiagnosis killed him.

“We didn’t know that previous hospital was simply wasting the time he had left, treating the wrong ailment even after we had sold everything we had to save his life, but he died eventually,” the heartbroken woman said.

Painful as it is, Hannah’s grief is not peculiar, her husband is among at least 100,000 diagnosed cancer cases in Nigeria annually, according to the World Health Organisation, out of which about 80,000 die, due partly to misdiagnosis. The WHO stressed that early detection was key in successfully treating any oncological disease.

In fact, the case of late Chief Gani Fawehinmi (SAN), one of Nigeria’s foremost human rights activist, is also instructive, as it was another unfortunate case of wrong diagnosis, which has been tied to gross incompetence or negligence.

He had also been diagnosed with pneumonia and was undergoing treatment for that in Nigeria, but by the time his case got critical and he was flown abroad, correct diagnosis showed that he had cancer.

According to one of his children, the erudite and fearless lawyer burst into tears on hearing that he was suffering from cancer. Unfortunately, by that time, the cancer had reached an advanced stage. He later died of the same ailment.

The list of such misdiagnosis is almost endless, likewise is the avoidable deaths.

Experts, shedding more light on the danger of the situation, explain that apart from causing avoidable deaths, misdiagnosis could also leave victims battling new and strange ailments and could condemn them to permanent disabilities in the process.

An open sore

While some experts in the medical field finger error on the part of poorly trained doctors as among major factors fuelling this scourge, others say the lack of adequate modern equipment to aid practitioners in arriving at informed decisions is responsible for the situation.

Professor of virology and Fellow of the Academy of Science of Nigeria, Oyewale Tomori, said cases of misdiagnosis should not even come up, whether they lead to death or not. He said it was a development that called for urgent action.

He said, “My personal view, based on my experience as a veterinarian with laboratory expertise, is that issues of misdiagnosis vary from poor equipment and the lack of resources to make the correct diagnosis, to poor analysis and interpretation of even correct observations, facts and results.

“In the case of our health centres, many lack the appropriate equipment or machines, or in some cases, poorly maintained equipment and machines. Add to this, the issue of lack of reagents and supplies to make the right diagnosis.

“We often contend with poor quality and standard of laboratory services offered by incompetent ‘experts’. Each or combinations of these situations can contribute to wrong diagnosis of disease conditions,” he said.

Speaking further, Tomori said to avoid deaths and needless complications that could accompany wrong diagnosis; the federal and state governments should provide better machines and equipment, insisting that there is need also to equip operators of such machines with relevant skills needed to save lives.

He said, “Poorly trained staff will not only ruin the equipment, but also misinterpret the results that good equipment produce. So, we need appropriate equipment and machines, high quality reagents and supplies in adequate quantities, maintained or stored as recommended, plus well trained laboratory technologists and physicians who keep themselves abreast of modern development and advances in medicine and laboratory diagnosis.”

Consultant paediatric haematologist and oncologist, Prof. Aderemi Ajekigbe, while also commenting on the issue, said most equipment that would have provided confirmatory evidence of patients’ ailments were not available in most hospitals, thus aiding the platform for doctors to make costly errors by way of misdiagnosis.

“If a patient has problem with breathing and the person is coughing; we call that differentials in medicine, a million things could be wrong and the doctor may be looking at other things, except cancer. But when you use the right equipment to examine that person, it gives you direction and when all the facilities are available, the diagnosis and treatment are on track,” he said.

Apart from the huge impact of the lack of equipment, Ajekigbe said wrong diagnosis could also come about when people are not able to pay for all the tests they are meant to do, thus a doctor’s conclusion, based on the few tests conducted, might not be sufficient to make the right diagnosis.

“Abroad, a patient doesn’t pay out of their pocket, there is health insurance and they have equipment to take care of everything.

“But over here, majority may not be able to pay for all the tests needed to accurately diagnose an ailment, because they could be expensive. However, those who have the money haven’t got the will to buy the machines and help those who cannot pay for it. These equipment can be funded by the government, but some people steal the money and keep it under their bed. That is why we are where we are now,” he added.

To strengthen the argument that lack of equipment is indeed responsible for some avoidable deaths and complications that people suffer, Ajekigbe said with about 180 million people, Nigeria needs not less than 200 radiotherapy machines, but that at the moment, the country had about eight, out of which not more than two work at any given time.

“That could lead to delayed treatment, or not having adequate treatment or not being treated at all and you know what that means,” he said.

While hospitals in urban areas could make do with the handful of equipment and few specialists, people in the rural areas experience worse situation because of the lack of equipment. In fact, in some rural health centres, there are no standard laboratories for carrying out tests, leaving doctors in such places to rely only on clinical judgement, and then opening up bigger room for misdiagnosis.

Findings by Saturday PUNCH revealed that many hospitals in Nigeria today do not have the necessary diagnostic machines, which should provide confirmatory evidence.

A public health consultant, Dr. Rotimi Adesanya, also ascribed wrong diagnosis to lack of equipment and inadequate expertise, stressing that doctors sometimes need certain machines to confirm their clinical observation, and that in the absence of that, misdiagnosis might be an eventual outcome, especially when the patient does not have enough money to do all the necessary tests.

Adesanya pointed out that to save more lives, government should not waste time in providing equipment in public health institutions and that it should make loans – at subsidised interest rate – accessible for private hospitals to also procure necessary machines, noting that the cost of wrong diagnosis could not be quantified when compared with human life.

‘An unjustifiable occurrence’

But as understandable as the argument about equipment may appear, the President of the Nigerian Medical Association, Prof. Mike Ogirima, said there was no excuse for wrong diagnosis.

He stressed that a doctor who knew his onions would not diagnose a patient wrongly, regardless of lack of equipment, saying it was the same reason well-trained doctors should have differential diagnosis. He said instead of diagnosing a patient wrongly, a doctor should seek a second professional opinion.

He said, “If you make a diagnosis that you are not 100 per cent sure of, then you may want to say there are other conditions that could be responsible. So, wrong diagnosis should not come up at all. Why should you make a wrong diagnosis? Instead of that, you could say you are querying it. You can err on that side and people would know that as a scientist, you are thinking widely on the diagnosis, than put a patient’s life at risk.

“With adequate training and good experience, we won’t have such incidences. I mean someone who has been in a field for five years would not make that mistake. Wrong diagnosis may be very common among younger colleagues and not the experienced hands.”

He said doctors should be available for retraining and recertification always, noting these, coupled with specialising in one field, are good ways to minimise wrong diagnosis.

He said, “For our younger colleagues, I always advise them to go back for learning through residency programme. It’s like going back to school. It’s a good way of minimising wrong diagnosis. They should try and specialise, so you won’t say you are a master of all the illnesses. And if they decide to be in general practice, it also has graduate training programme called family medicine.

“We do retraining and recertification often every year and a doctor is supposed to have a minimum number of continuous professional development points. You have to present such before you are allowed to practise in the coming year. It is a minimum requirement.”

A curable scourge complicating people’s lives

While there are no available statistics on the number of deaths or complications resulting from misdiagnosis annually, findings by Saturday PUNCH reveal that this scourge continues to claim dozens of victims across the country.

The case of four-year-old Adamu Rukayya from Kaduna State is particularly pathetic. The little girl had one of her legs amputated as a result of wrong diagnosis. Ever since, the four-year-old, who has been walking with the aid of crutches, cry ceaselessly, demanding for the whereabouts of her leg.

Her uncle, Abubakar, told our correspondent that Rukayya had on October 6, 2016 complained of a headache and her parents took her to a private hospital. She was given some drugs but instead of getting better, her condition worsened. They went back to the hospital and the doctor said she needed blood transfusion and that it would be done through one of the veins in her leg because he could not find any on her hands. But after the transfusion, while the initial ailment she complained of had yet to abate, her leg began to swell. And by the time the private hospital referred the case to the Ahmadu Bello Teaching Hospital, the doctors there said the leg had already been infected and had to be amputated to prevent damage to other organs of her body. The little girl lives with the pains till date.

In yet another sad loss, family members and friends of Mr. Chidi Obi, a native of Ebonyi State, said he would not have died if his ailment had been rightly diagnosed at a public health centre where he was taken to a few years ago. Ogbonna, son of the victim, said even though the incident happened in 2012, the pain of the “premature death” had yet to heal.

He recalled that their trouble started when a doctor they met at the hospital started pressing his phone after his father narrated the way he was feeling. As it turned out, he said he later found out that the doctor was checking for information on the ailment online, to the extent that he also brought out a big book from his drawer and was flipping through until he reached a certain page and he read from the book what his father was suffering from.

He said, “He was a young doctor, looking like someone that had just graduated. He closed the book and recommended the drugs we were to buy, all of which cost N6,700. When we got home, his situation was gradually deteriorating. He was becoming weak and unable to move his body very well. We called the doctor, who told us he would be fine and that all he needed was rest.

“He was 74 at that time and some family members said his time was up because he was no longer a young man. But I knew the doctor’s diagnosis was faulty and that quickened his death. I believe he was wrongly diagnosed while the original ailment was killing him, because the chronic cough he complained of initially never stopped till his death.”

In yet another case, Mrs. Uloma Eke, who had just been delivered of her baby in the United States of America said her Nigerian doctors had told her that she would be delivered of her baby through Caesarean Section because she had sexually transmitted infection. She had already been given the estimated cost of the operation, but when she got to the US, she said she did some tests and the doctors there told her she was fine and would not need CS.

“They said I didn’t have any infection and that I would have normal delivery without stress,” she said. “Today, my baby is one month old and I had her through normal delivery. If I had been delivered of my baby in Nigeria, imagine what I would have gone through and the money I would have spent,” she added.

Also, perhaps Mrs. Tosin Adewale would have been blaming herself now if she didn’t get a second opinion over an ailment that threatened her well-being two months ago. A doctor in a popular hospital in Ikeja, Lagos had told her she had toilet infection and then prescribed drugs for her. But on getting to another hospital when the ailment didn’t subside, she was found to have typhoid.

“When I finished my treatment, I went back to that former hospital to collect my money and shout on the doctor. He begged me not to escalate it and that ‘we are all human beings and errors could sometimes be inevitable.’ If I didn’t go to another hospital, the typhoid would have reached an advanced stage and I would be taking drugs that I didn’t need,” she said.

A glaring solution to a biting problem

Perhaps, if a fraction of the billions of naira budgeted yearly for the health sector had been spent on acquiring modern diagnostic machines and such machines had been distributed across the country, Hannah’s husband, Ogbonna’s father and several others might not have lost their lives prematurely.

But with the amount budgeted for capital expenditure in the health sector, it would appear that misdiagnosis is something Nigerians would have to live with for a long time.

For example, in the 2017 budget, N304bn was budgeted for the health sector, out of which a whopping 83 per cent, about N252bn, was for recurrent expenditure and a mere 17 per cent, about N51.6bn was for capital expenditure. The health budget was just 4.17 per cent of the entire 2017 budget.

While that was seen as inadequate for a sector that needed critical intervention, the 2016 budget was even lower, at N282.1bn, out of which N221.7bn was for recurrent expenditure, while a paltry N35.6bn was for capital expenditure.

Also, in 2015, the total sum allocated to the health sector was N280.5bn, out of which N237bn was budgeted for recurrent expenditure and N22.6bn was for capital expenditure.

The budget for the health sector also covers the Federal Ministry of Health, the agencies and parastatals under it and other health projects including the National Action Committee on Aids.

In effect, given the paltry sum allocated to capital projects, one could surmise that absence of equipment may remain a recurring problem because the capital budget for the ministry could hardly run the 24 teaching hospitals, 36 general hospitals and 22 federal medical centres, not to talk of buying equipment needed in each of the hospitals, more so that some of the medical equipment cost tens and hundreds of millions of naira.

And for the private sector, it seems like a more costly venture, especially if they hope to take loan from the bank. On the website of the Central Bank of Nigeria, as of the time of filing this report, maximum lending rate as of March 2017 stood at 30.18 per cent, which, according to the managers of some private hospitals, was a no-go-area.

The startling revelation by the wife of President Muhammadu Buhari, Aisha, few days ago about the appalling state of the State House Clinic, which should take care of the medical needs of the President, his Vice, their immediate family members and top government functionaries, also gave a clearer picture of how much equipment deficit there are in the Nigerian hospitals.

Aisha lamented that she had called the clinic to know if the X-Ray machine, a major diagnostic equipment, was working but that she was told it was not. Thus, she had to use another hospital established by foreigners.

The cost of X-Ray machines range between $95,000 (N35m) and (N46m), and thankfully, the sum of N3.87bn was budgeted for capital projects at the State House Clinic in the 2016 budget, but that didn’t translate to better facilities at the clinic. And in 2017, the budget was reduced to N331.7m.

But, regardless, the said sum would still have bought at least one X-Ray machine.

This partly explains why top government officials travel abroad for treatment, knowing that Nigerian hospitals are in shambles and being fully aware of the inherent danger in such.

President, Muhammadu Buhari, his Chief of Staff, Governors, Atiku Abubakar as the then Vice-President, and other top officials always prefer to travel abroad for check-up or treatment, leaving the rest of Nigerians to battle with the country’s ailing health sector.

Atiku had travelled for mere hip injury, while the current Minister of  State for Education, Prof. Anthony Anwuka, was said to have been hospitalised in the United States few days ago.

Meanwhile, findings by Saturday PUNCH reveal that in the countries that Nigerians run to for medical care, huge sums of money and a significant part of their budget is spent on the health sector.

India, one of such medical destinations for Nigerians, in its 2017 fiscal year, said it was henceforth increasing fiscal health spending to 2.5 per cent of the Gross Domestic Product, to guarantee quality health care to all citizens, particularly the underprivileged.

As of 2016, India’s GDP was $2.26tn and the 2.5 per cent would be about $56.6bn (about N20tn).

As of 2015 when Nigeria budgeted 5.5 per cent of its budget to the health sector, China allocated 12.6 per cent, the United States 20.7 per cent, Turkey 10.7 per cent, Germany 19.4 per cent and Iran 17.5 per cent.

Notably, for years, Nigeria had been shuttling between 3.6 per cent and 5.5 per cent, which is grossly below the 15 per cent agreed on by the WHO and Heads of States (Nigeria inclusive) under the African Union umbrella at a forum which held in Nigeria.

While poor budgetary allocation had effectively contributed to the lack of equipment in the nation’s hospitals, findings also showed that one other factor that has contributed immensely to wrong diagnosis is poor training of doctors at the various medical colleges.

Investigations by Saturday PUNCH reveal that facilities in many medical colleges are overstretched, which has a negative impact on the quality of training in the colleges. For example, in one of the colleges visited, there were as many as 70 to 80 students to a cadaver, instead of about 10. As observed, some students who couldn’t partake in the learning process, due to the crowd, fiddled with their phone while some simply walked out of the class.

“That picture you just painted poses a threat to effective learning,” said Ayo Adeyemi, a medical doctor. He added, “we need to expand our facilities and make sure that quotas are not exceeded by colleges of medicine, because the lives of human beings would depend on the judgment and actions of these medical students once they leave school, so the training process needs to be overhauled.”

Another perspective to human error is the shortage of medical personnel, which leads to fatigue. Saturday PUNCH had reported that in gross deficit of the standard set by the WHO that there should be one physician to 600 patients, in Nigeria, it is one physician to 3,500 patients, which, sadly, overburdens available physicians with work. This view was also echoed by the NMA President.

A medical doctor (names withheld) at the Lagos University Teaching Hospital said the pressure of attending to many patients in a day could make a doctor commit an error.

“The situation in our hospitals is really pitiable. The crowd compels you to overwork yourself and who says you can’t make mistake when there is fatigue?” he said.

For persons in need of specialists’ services, the situation is the same – there is 13,000 deficit in Nigeria, making work and life tough for the available 5,348 registered specialists. As a result of this problem, Nigerians spend around $1bn annually on medical tourism, one of the highest in the world.

Minister of Health, Prof. Isaac Adewole, had said in 2016 while presenting certificates to three laboratories selected by the International Organisation for Standardisation, that without proper diagnosis, health care delivery would be meaningless.

A helpless bulldog?

Reacting to the situation, the Medical and Dental Council of Nigeria, a body set up to regulate and ensure good medical practice in Nigeria, said instead of going to the social media to complain, people who feel dissatisfied with doctors’  diagnosis or treatment should file their complaints with the council.

A top official of the council, who spoke to our correspondent on the condition of anonymity, said what people call wrong diagnosis did not stand alone, insisting it could either be tied to misconduct or negligence, which, according to him, are manifestations of gross incompetence.

He said punishment for any of the two ranges from admonition, suspension for a period not more than six months to erasure of the person’s name from the register, in which case the person would not be able to practise in Nigeria or any other country it has pact with.

He said there had been an increase in the number of complaints filed with the council because people are becoming more aware of the council’s mandate in that regard. According to him, between January and August this year, a total of 40 complaints had been duly filed with the council.

The official explained that from previous reports and investigations, the reasons for this ranged from human error to inadequate resources, like manpower, adding that, “For example where you are supposed to have five doctors you have one. By sheer fatigue, the doctor is likely to make a mistake.”

While revealing that the council encourages people to report if they believe that a doctor, in the course of attending to them, did something wrong, the official said that such a person must submit a report in form of a proper affidavit, signed by either the Commissioner for Oaths or a Notary Public. He stressed that any complaint so filed by the commission would surely be entertained.

“The process takes time because the law stipulates the time frame for each of the stages; from when the complaint was received to when the doctor responds, also in the form of an affidavit, to when the panel members – all doctors and dentists – review the case individually. From where it proceeds to the disciplinary tribunal for trial if majority of the doctors vote that the doctor has a case to answer.”

The source pointed out that due to the delay by the Federal Government in constituting the board of the MDCN, about 70 cases had been pending before the disciplinary tribunal, a situation he says frustrates their ability to dispense with cases and punish erring doctors swiftly.

- Saturday Punch

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