Achilleus-Chud Uchegbu… Giving an insight into the severity of his illness on returning from his medical vacation, President Muhammadu Buhari revealed that he had blood transfusions and several visits to the laboratories. This gives some insight on the indispensability of the clinical laboratory in healthcare delivery, especially in critical care medicine. President Buhari simply summarised what the world knows about clinical laboratory, that it is an indispensable backbone of excellent clinical medicine. Some literatures bring in clinical laboratory services as necessary adjuncts in the health management system. For instance, in the Report of the Review of NHS Pathology Services in England, chaired by Lord Carter of Coles, it was held that “Pathology services lie at the heart of the health care services provided to patients. They are essential to the delivery of many of the national priorities and targets for the NHS. It is estimated that 70-80 per cent of all health care decisions affecting diagnosis or treatment involve a pathology investigation, with individuals’ treatment decisions –and the monitoring of their response to treatment – often dependent on a range of pathology-based tests and investigations.”
The report further held that “many of the issues identified in this report stem from the recognition that pathology needs to be managed in future as an end-to-end clinical service in its own right – both as a provider of optimal laboratory based services and a core contributor to the clinical aspects of the patient’s journey. We consider that pathology services should be commissioned on that basis, with a service specification which enhances efficiency and effectiveness and improves service quality. This approach should help, in part, to raise the profile of pathology services as a key provider specialty in health care.”
If clinical laboratory is this important in healthcare delivery and significantly contributes to the results in reduction of morbidity and mortality from diseases, why then are our governments and health administrators paying lips-service to issues of clinical laboratories? The importance placed in the laboratories by governments of the developed countries as widely expounded in the Carter report could easily explain why simple diseases that defy diagnosis in Nigeria are easily diagnosed abroad.
An attempt to do a critical review of our hospital laboratories, both public and private can only evoke sad memories. The entire places are littered by obsolete and non-functional equipment manned by very rude and uninspiring staff churning out near death certificates in the name of results. Very often doctors simply ignore or discard those results when presented to them and resort to relying on their clinical judgement. Perhaps only teaching hospitals can give out averagely accurate results. In many of the laboratories in general hospitals results are written on sheets of exercise book or any piece of paper available including plain part of newspapers. In most of the private laboratories you are lucky if your disease goes outside typhoid or staphylococcus or low Hb.
President Buhari received blood transfusions, most probably with ease. Receiving such service in Nigeria is fraught with excessive stress ranging from extortion by laboratory staff to huge bills collected to sell the blood and delays in delivering the blood to the doctors for the eventual transfusion. There is a large market of blood touts operated and sustained by laboratory staff around virtually every hospital in the country. A bag of blood is sold for between N10,000 and N20,000 by these unholy marketers, the vampires of our health system.
As bad as the above scenario might appear, it becomes insignificant when compared to the damage done to the clinical laboratories by the endless supremacy battle between pathologists and medical laboratory scientists. This has been going on for over fourteen years while the Federal Ministry of Health watches with hands akimbo, presumably enjoying the fallouts from the battles. The dead silence of the Federal Ministry of Health (FMOH) over a prolonged crisis rocking a very important component of patients care got one concerned as to whether there are different clinical laboratories for blacks and whites, or whether the care of the lives of blacks do not require the laboratories. Why should FMOH allow her employees to quarrel over work or workplace? Who owns the workplace and who assigns responsibilities? Who hires and who fires? Except the axiom has changed, it is always said that he who hires fires; he who employs assigns duties and responsibilities. Why should recalcitrance, insubordination, obstruction to duties, contamination of reagents, locking up of laboratories by one group of staff against others as widely reported, be allowed to destroy not only our national assets but sacrifice the lives of Nigerians. Many innocent Nigerians have perished or been irreversibly harmed by wrong or poor quality results from our laboratories.
May be the FMOH and Nigerians need to be reminded about the clinical or medical laboratory.
The Free Encyclopaedia Wikipedia defines “A medical laboratory or clinical laboratory as a laboratory where tests are usually done on clinical specimens in order to obtain information about the health of a patient as pertaining to the diagnosis, treatment, and prevention of disease”. It went further to say that what is practised in the medical laboratory is a part of laboratory medicine! This is a fact that can lay whatever rivalry-turned quasi militancy existing today among professional groups in Nigerian public healthcare settings to rest.
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Going further, Wikidepia explained that this laboratory medicine encompasses on one hand, Anatomic Pathology which has the following component units: Histopathology, Cytopathology, Autopsy Pathology and more recently Molecular Pathology and Cytogenetics which is also studied along with the mother medical specialty known as Genetics. On the other hand is Clinical Pathology which includes: Clinical Microbiology comprising five different sciences (units), namely bacteriology, virology, parasitology, immunology, and mycology. Other components of Clinical Pathology are- Clinical Chemistry (also called Chemical Pathology)_ which is concerned with the instrumental analysis of blood components, enzymology, toxicology and endocrinology; Haematology and Blood transfusion; and Reproductive Biology comprising semen analysis, sperm banking and assisted reproductive technology.
Still courtesy of Wikipedia, we further learn that several personnel work as a team in the laboratory to deliver on its mandate of contributing to patient care. These in hierarchical order are Pathologist, Clinical Biochemist, Pathologists’ Assistant (PA), Biomedical Scientist (BMS) in the UK, Medical Laboratory Scientist (MT, MLS or CLS) in the US or Medical Laboratory Technologist in Canada, Medical Laboratory Technician (MLT in US), Medical Laboratory Assistant (MLA), Phlebotomist (PBT). Other non-health care personnel who assist in day to day running of laboratories include clerical officers/computer operators, cleaning staff, dispatch riders/delivery staff and security guards.
Given these clear cut lines of professionalism, why is the Nigerian health sector witnessing its ugliest experience in terms of viral industrial disharmony that has its origins in the dichotomous relationship between laboratory scientists and pathologists? Medical laboratory scientists are said to be claiming sole professional territorial ownership of the clinical laboratories and wish to supplant the pathologists who several literature have acknowledged as the leader in terms of hierarchy of the medical laboratory according to international best practices? This is akin to the bricklayer trying to supplant the structural engineer at the construction site or a certified midwife claiming sole professional territorial ownership of the labour room and locking out the Consultant Obstetrician. A search into the origins and development of these two professions is very revealing. There was no profession called Medical Laboratory Technology or Medical Laboratory Science until Laboratory Physicians (Pathologists) established it in late 19th to early 20th century as assistants to them (Pathologists) in their practice. The Pathologists developed the programme and curriculum, and carried out the training and certification. The first person awarded a formal certificate after a structured training was Paul H. Adams of Fort Worth Indiana in the USA in 1930 under the platform of the Board of Registry of the American Society of Clinical Pathologists (ASCP). ASCP remains the most prestigious certification body despite the existence of many others in the US and this impact positively on the earning of professionals certified by ASCP.
Pathologists practiced for many centuries before they brought in assistants who are today’s laboratory scientists and delegated some aspects of the practice to them, while retaining overall technical supervisory and administrative leadership, as well as giving meaning to laboratory generated data, and discuss with the clinicians about patient care and the need for further investigation where necessary. The situation has not significantly changed till date even though the medical laboratory scientists have been given or allowed more responsibilities as their professions evolved. Pathologists still retain the responsibilities for the complex aspects of the practice, and are liable for any adverse result from the clinical laboratories. It sounds ironical and strange that the professional who takes responsibility for adverse outcomes is being challenged by its allied support service providers, to the point of claiming sole ownership of the work environment. No individual or group can claim ownership of any part of any public institution where he or she has been employed to work. The Chief Executive Officers of these institutions must stand up to their responsibilities and apply necessary sanctions against anyone whose conduct is inimical to high quality service to patients and the community at large
It is saddening that the FMOH and policy makers in Nigeria appear indifferent to practices in other climes where sanity reigns and quality care the watch word of the care givers. All the bickering would have been rested had the FMOH paid closer attention and played its role as supervising ministry. Do Nigerians deserve less than their fellow human beings in the developed world. Sadly, those details seem not to have attracted attention of health policy makers in Nigeria. Perhaps, the bickering, which is negatively impacting healthcare management, would have been rested had the Federal Ministry of Health paid closer attention. Is Nigeria then a banana republic?.
Drawing an insightful inference from another Commonwealth country, the Royal College of Pathologists of Australia (RCPA), in a Nov 2016 position paper, identified several roles of the pathologist which it said are “specific”. These include expert in clinical interpretation of diagnostic tests and an understanding of the nature and causation of disease processes; expert in understanding the principles of analysis and technical details of tests used to diagnose and monitor disease; expert in the development and assessment of new testing methodologies; expert in knowing the appropriate test to be performed: in a specific clinical situation (“the right test at the right time for the right patient”); expert in interpretation of individual and groups of test results and the significance these results will have on patient management; expert in quality methodologies in the laboratory; expert in safety requirements for laboratories and expert in the effect of disease and therapy on laboratory tests.
The position paper also identifies a pathologist as a manager who supervises and manages a laboratory effectively; uses personal resources effectively to balance laboratory and clinical skills along with own individual learning needs; uses available health care resources appropriately and effectively; works effectively and efficiently in the provision of pathology services and provides clinical direction.
It says the pathologist is specifically an expert, a communicator, a manager, a collaborator (consulting with other medical practitioners and health care professionals), a health advocate, a scholar, teacher and researcher and lastly, a professional who delivers the highest quality service with integrity and honesty, demonstrates appropriate personal and interpersonal behaviour and practices pathology ethically, consistent with the obligations of a medical specialist. Since the pathologist had been variously assigned managerial as well as supervisory roles by those who our people run to for medical tourism, there is a need for a better understanding of this simple clear cut professional distinction between the pathologist and the Medical Lab scientists. The rivalry appears not to exist elsewhere on the surface of the earth apart from Nigeria.
The case of Baby Oyinkansola Eniola at the Lagos State University Teaching Hospital (LUTH) Idiaraba in 2006 readily comes to mind. Newborn Baby Eniola was taken to LUTH on account of ill-health which necessitated blood transfusion. Due to the carelessness of the laboratory staff she was transfused with HIV positive blood. A Federal Government panel of inquiry indicted a number of people in the unfortunate event. The Chief Medical Director of the hospital Professor Tolu Odukoya, was sacked, the Chairman , Medical Advisory Committee (CMAC) of the hospital as well as Dr. C.C. Okanny, head, Department of Hematology and Blood Transfusion were relieved of their appointments with immediate effect., Dr. A.S. Akanmu, a Consultant Haematologist and blood transfusionist received a serious warning to be more careful and responsible in providing effective leadership in the running of the laboratory and the blood bank. This position of the Federal Ministry of Health is a clear demonstration that it recognises the leadership role of consultant pathologists in clinical laboratories. It therefore beats the imagination of all well-meaning Nigerians why the same Ministry has been looking the other way while our hospital laboratories churn out death certificates in the name of laboratory results, a situation everyone attributes to the crises in the clinical laboratories.
In the Daily Trust Newspaper editorial of May 10 2013, the House of Representatives lamented the rot in the clinical laboratories following a startling revelation made by the then President of the Association of Pathologists of Nigeria (APN), Dr Kenneth Iregbu. In a press conference earlier, Dr Iregbu had sounded the alarm that half of all test results obtained in Nigerian medical laboratories were unreliable. The Association attributed this to the preponderance of fake and substandard medical laboratories all over the country, whose activities led to wrong diagnoses by physicians and sometimes deaths. The House of Representative described the situation as alarming and a real cause for concern because of the danger it posed to people and the health sector. The House had appealed to the APN to come to the rescue of the nation before things got out of hand. It is doubtful if things have not gotten worse since then as the war rages on.
Many refer to the enactment of the MLSCN Act 11 of 2003 for the regulation of the profession of medical laboratory science, as the source of the problem, and the consequential interpretations of the provisions of that legislation by some lawyers and judicial officers who appear misinformed.. The Act in Section 4 (e) provides that the MLSCN “regulate the production, importation, sales and stocking of diagnostic laboratory reagents and chemicals; and in 4(f) inspect, regulate and accredit medical laboratories”; Ironically the Medical and Dental Practitioners’ Act 1992 (as amended) states that the MDCN shall make regulations for the operation of clinical laboratory practice in the field of Pathology and its sub-specialties. To a discerning mind there is no obvious conflict in these two Acts. It is against natural justice for a subordinate and a profession allied to a core medical speciality to exercise any form of control over the medical speciality in a common workplace. It is now clear from the preponderance of evidence that the practice of the laboratory is actually a medical practice in the field of pathology. If there is a conflict what has the FMOH done about it? What of the Federal Ministry of Justice? Did the National Assembly consult well? Did the National Assembly make any effort to what happens in countries where Nigerians go for foreign medical treatment?
A closer look at the functions of the MLSCN and the definition of medical laboratory science in the Act will suggest that the medical laboratory science is a non-specific profession. It would appear that its scope cuts across health, fabrication, design and manufacturing industries. It is a general purpose profession. A senior research officer with the Nigerian Institute of Medical Research who spoke under anonymity informed our reporter that abroad pathologists, medical laboratory scientists, research scientists and others are the best of friends and have very exciting relationships because they are the ones that produce the evidence for quality health care and medical advances, with the Pathologist leading the pack in a hospital laboratory. She added that in research either the pathologist or any senior research scientist leads depending on the subject of study. Any medical laboratory scientist who wants to lead in clinical research will either change cadre to research scientist by obtaining a PhD or go back to school to become a pathologist. Sadly in Nigeria medical laboratory scientists want to drive everybody away from the laboratory and no one seem to care about the serious damage it is doing to our health system and research community. It is difficult to make any sense out of any result from their so called labs, and that is why researchers are seriously avoiding collaborations with us, she concluded.
A consultant physician with Holy Cross Hospital, Surulere, Lagos, Dr A. B Olorunda, lamented that the crisis in the clinical laboratories has robbed Nigerians of a very vital segment of quality health care. According to him, he will go to sleep if he knows that any lab result coming to him has the input of pathologists because such inspires confidence and gives a substantial level of assurance that it is accurate and that somebody is there to take responsibility should anything go wrong. He regretted that what they are getting from the laboratories around is sad as most are laboratory results are of no use in taking serious decisions. He called on relevant authorities to do something about this. He described it as hypocrisy that people go abroad to enjoy quality health care services put in place by the same professionals, only to look away from local challenges that deny tax-payers the same quality services. He implored government authorities who go abroad to enjoy the excellent services provided by Pathologists and their medical lab technologists to take action to put the same services here for the benefit of other Nigerians.
In conclusion, it behoves the FMOH that recently instituted a position statement and made clarifications regarding a judicial pronouncement bothering on the marketing and consumption of Fanta and Sprite produced by the Nigerian Bottling Company with uncommon speed and alacrity, to save Nigerians from avoidable deaths resulting from the current war in the clinical laboratories. The buck actually stops at the Ministry’s desk.
*Uchegbu is a journalist and writes from Lagos.
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