\\n\\n
Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\\n\\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\\n\\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\\n\\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\\n\\nThank you all for being part of the journey. 5,000 times thank you!
\\n\\nNow with 5,000 titles available Open Access, which one will you read next?
\\n\\nRead, share and download for free: https://www.intechopen.com/books
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Preparation of Space Experiments edited by international leading expert Dr. Vladimir Pletser, Director of Space Training Operations at Blue Abyss is the 5,000th Open Access book published by IntechOpen and our milestone publication!
\n\n"This book presents some of the current trends in space microgravity research. The eleven chapters introduce various facets of space research in physical sciences, human physiology and technology developed using the microgravity environment not only to improve our fundamental understanding in these domains but also to adapt this new knowledge for application on earth." says the editor. Listen what else Dr. Pletser has to say...
\n\n\n\nDr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\n\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\n\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\n\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\n\nThank you all for being part of the journey. 5,000 times thank you!
\n\nNow with 5,000 titles available Open Access, which one will you read next?
\n\nRead, share and download for free: https://www.intechopen.com/books
\n\n\n\n
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\r\n\r\n\tMortality rates are high for emergency surgeries. The most advanced surgical techniques are used (open surgery and laparoscopic surgery, damage control surgery for polytrauma patient management, advanced multidisciplinary management of acute and non-acute surgical patients). The Unit prides itself on the collaboration between multidisciplinary teams that make use of advanced diagnostic and therapeutic resources. General surgeons are assisted by physicians from the traditional radiology, interventional radiology, angiography and anaesthesiologists-resuscitators, to allow for a timely diagnosis and optimal treatment of urgent and non-urgent pathologies.
",isbn:"978-1-83969-524-7",printIsbn:"978-1-83969-523-0",pdfIsbn:"978-1-83969-525-4",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,hash:"a07902d256cd9902e2291fa7bf2322af",bookSignature:" Selim Sözen and Associate Prof. Burhan Hakan Kanat",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10713.jpg",keywords:"Cardiovascular Surgery, Aneurysm, Bypass Surgery, Neurosurgery, Spinal Trauma, Head Injury, Orthopedics, Fracture, General Surgery, Urology, Anesthesia, Reanimation",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 16th 2021",dateEndSecondStepPublish:"March 16th 2021",dateEndThirdStepPublish:"May 15th 2021",dateEndFourthStepPublish:"August 3rd 2021",dateEndFifthStepPublish:"October 2nd 2021",remainingDaysToSecondStep:"14 days",secondStepPassed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"Dr. Selim Sözen is a member of the Turkish Surgical Society and International Pilonidal Society. He is an author of 105 publications including 5 book chapters, as well as a review board member of several journals.",coeditorOneBiosketch:"Dr. Burhan Hakan Kanat is a member of the Turkish Surgical Society, International Pilonidal Society, and Turkish Society of Colon and Rectal Surgery. He is an author of more than 100 publications including 5 book chapters.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"90616",title:null,name:"Selim",middleName:null,surname:"Sözen",slug:"selim-sozen",fullName:"Selim Sözen",profilePictureURL:"https://mts.intechopen.com/storage/users/90616/images/system/90616.jpg",biography:"Dr. Selim Sözen was born on 01.01.1973. He graduated from the Faculty of Medicine, Ondokuz Mayıs University, Turkey in 1998.\nHe trained in general surgery at Ankara Atatürk Education and Research Hospital in Turkey (2004). He worked as a specialist\nat different Government Hospitals in Turkey (2004-2013). He started to work as an Associate Professor at the Department of General Surgery of Medicine Faculty of Namık Kemal University (2013). He completed liver transplantation surgery at İnönü University (General Surgery Department, 2014–2015, Turkey) Fellowship Programs. From 2016, he has worked as a Specialist at his own clinic in İstanbul, Turkey. He is a member of the Turkish Surgical Association. His clinical interests include treatment, surgical procedures, surgical techniques, laparoscopic surgery, minimally invasive surgery, gastrointestinal surgery, hernia surgery, colorectal surgery, surgical oncology, hepatopancreatobilliary surgery, bariatric surgery for morbid obesity, bariatric medicine, endocrine surgery, esophageal diseases, breast surgery, and esophagectomy. Dr Sözen is an author of 105 publications including 5 book chapters, as well as a member of review boards of several journals",institutionString:"Sözen Surgery Clinic",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"1",institution:null}],coeditorOne:{id:"183319",title:"Associate Prof.",name:"Burhan",middleName:"Hakan",surname:"Kanat",slug:"burhan-kanat",fullName:"Burhan Kanat",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRHhvQAG/Profile_Picture_1605515370315",biography:"Dr. Burhan Hakan KANAT was born on 1981 in Malatya/ Turkey. He graduated from the Faculty of Medicine, İnönü University, Turkey in 2005. He trained in general surgery at Fırat University Faculty of Medicine in Turkey (2011). He worked as a specialist at the Elazığ Training and Research Hospital in Turkey . In 2013, he received a Certificate of Surgical Competence from the Turkish Surgery Society. He completed liver transplantation surgery at İnönü University (General Surgery Department, 2014–2015, Turkey) Fellowship Programs. He received training in breast-endocrine surgery in 2016.He became an associate professor in 2017 from Head of Inter-University Council. And He worked as an Associate Professor at the Department of General Surgery of Medicine Faculty of Health Sciences University (2018-2020). He is a member of the Turkish Surgical Society , International Pilonidal Society and Turkish Society of Colon and Rectal Surgery . He started to worked as an Associate Professor at the Department of General Surgery of Medicine Faculty of Malatya Turgut Özal University (From October 2020) Dr.Kanat is an author of about more than 100 publications including 5 book chapters, as well as a member of review boards of several journals.",institutionString:"Malatya Turgut Özal University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"0",institution:null},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"347258",firstName:"Marica",lastName:"Novakovic",middleName:null,title:"Dr.",imageUrl:"//cdnintech.com/web/frontend/www/assets/author.svg",email:"marica@intechopen.com",biography:null}},relatedBooks:[{type:"book",id:"6550",title:"Cohort Studies in Health Sciences",subtitle:null,isOpenForSubmission:!1,hash:"01df5aba4fff1a84b37a2fdafa809660",slug:"cohort-studies-in-health-sciences",bookSignature:"R. 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The aim of anesthesia for these procedures is to improve patient’s comfort and endoscopic practice as well as patient and endoscopist satisfaction. The requirement for anesthesia is dependent on the type and duration of endoscopy, experience of endoscopist, and patient’s physical status. The anesthetic regimens for GIE procedures are quite different. Several guidelines from American Society of Anesthesiologists (ASA) [1] and American Academy of Pediatrics [2] are established. Appropriate pre-anesthetic assessment, anesthetic drugs used, monitoring practices and post-anesthesia care for anesthesia in GIE procedures are essential.
All patients scheduled to receive anesthesia/sedation should have a history and appropriate physical examination. Several risk factors including history of obstructive sleep apnea, alcohol or drug abuse, and history of adverse reaction to previous anesthesia/sedation are investigated. The patient physical status should be classified according to the ASA. The pregnancy test is recommended in women of childbearing age [3]. Consequently, written consent should be obtained. An anesthesia consultation should be done in high-risk patients including patients with respiratory or hemodynamic instability, obstructive sleep apnea, and high-risk airway management, as well as patients with ASA physical status >III and history of anesthesia-related adverse events.
Cardiorespiratory-related adverse events are a leading cause of morbidity and mortality associated with GIE procedures. Continuous monitoring of anesthetized patients is very important for safety. The physicians need to monitor the patients’ status throughout the procedure. Clinical observations including pattern of respiration, skin or mucosa color, and level or depth of anesthesia are continuously observed.
Pulse oximetry is a noninvasive device for continuous measurement of arterial oxygen saturation. Because clinical observation alone is inaccurate in the detection of hypoxemia, pulse oximetry has become a standard of care during GIE procedures. Oxygen saturation levels under 90% must be treated. However, pulse oximetry and oxygen supplementation do not diminish the severity or incidence of cardiorespiratory complications. In addition, oxygen desaturation is relatively a late sign [4].
Moreover, pulse oximetry and clinical observation cannot detect the development of hypercapnea. Capnography has been utilized to permit the safe titration of propofol by a qualified gastroenterologist during invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS).
Blood pressure and heart rate are important parameters of cardiovascular monitoring. The alterations of blood pressure are mediated by the depressive effects of anesthetic agents. Baseline hemodynamic parameters also provide useful information of the effects of various medical conditions. Generally, blood pressure and heart rate will be documented before anesthesia, and at least 5 min for deep sedation and general anesthesia, as well as every 15 min for mild and moderate sedation. Blood pressure is more likely to predict increasing and decreasing doses of anesthetic drugs.
The use of electrocardiography (ECG) was aimed to detect cardiac arrhythmias in high-risk patients undergoing anesthesia. However, the use of ECG during GIE procedure remains controversial [6]. American Society for Gastrointestinal Endoscopy (ASGE) and ASA practice guidelines recommend the use of ECG during GIE anesthesia in patients with significant cardiovascular diseases or arrhythmias. However, ECG is not recommended for routine use of ECG in patients with ASA physical status I or II [1, 4, 7].
Other monitors such as invasive arterial blood pressure, central venous pressure (CVP), and pulmonary arterial catheterization (PAC) are infrequently used during GIE anesthesia. However, these invasive monitors should be used in some high-risk patients including patients with severe hemodynamic instabilities and patients with shock.
The depth of anesthesia cannot be reliably judged by clinical assessments alone. Currently, the Bispectral (BIS) index has been reported to be more accurate in measurement of the depth of anesthesia. The BIS scale ranges from 0 to 100 (0, no cortical activity or coma; 40-60, unconscious; 70-90, varying levels of conscious sedation; 100, fully awake). In the past, BIS monitor was used to assess the patient consciousness during general anesthesia [4, 8]. To date, its use has subsequently expanded into the procedural sedation technique. However, the use of BIS during GIE procedures remains a controversial issue.
The usefulness of BIS monitoring for GIE procedure was confirmed by the study of Bower and colleagues. This study showed the correlation of BIS index and the Observer’s Assessment of Alertness/Sedation (OAA/S) scale for sedation during GIE procedures. It also suggested that a bispectral index near 82 corresponded with acceptable sedation level for GIE procedure [9]. Al-Sammak and coworkers compared BIS with clinical assessment for sedation during ERCP procedure in pediatric patients. The duration of sedation, recovery period, patient satisfaction, and total dose of sedative agents in the BIS group were better than in the clinical assessment group. This study demonstrated that BIS might be a valuable monitor for safe level of sedation and endoscopist’s satisfaction during ERCP [10]. Another study also showed that BIS monitoring guided to a decrease in the propofol dose for sedation in ERCP procedures. Mean BIS values throughout the procedure and during the maintenance period of sedation were 61.68 ± 7.5 and 53.73 ± 8.67, respectively [11].
In contrast, several reports demonstrated that BIS index had low accuracy for detecting deep sedation and it was not helpful for titrating propofol to an adequate depth of sedation level. For example, Chen and Rex evaluated the utility of BIS as a monitoring device for nurse-administered propofol sedation (NAPS) during colonoscopic procedure. The study showed the mean time required to accomplish BIS values ≤60 was significantly longer than the mean time required to achieve an Observer’s Assessment of Alertness/Sedation score of 1 (deep sedation). Additionally, there was also a lag time between the time required from the last dose of propofol and the time returned to baseline. The authors concluded that BIS index was not a useful device in titrating propofol to an adequate depth of sedation level [12].
Drake and coworkers also confirmed that BIS did not lead to the reduction in mean propofol dose or recovery time when used for sedation in colonoscopy [13]. Moreover, an observational study also showed that BIS index had a low accuracy for detecting deep sedation because of an overlap of scores across the sedation levels. Further improvements in BIS are needed to differentiate deep from moderate sedation for GIE procedures [14].
NarcotrendTM accomplishes a computerized analysis of the raw EEG. A statistical algorithm is used for analysis, resulting in a six-stage classification from A (awake) to F (general anesthesia/coma) and 14 substages [4, 15]. Wehrmann and colleagues evaluated 80 patients who underwent ERCP procedures by using EEG monitoring and clinical assessment for sedation. Their study demonstrated that mean propofol dose, decrease in blood pressure, and recovery time in the EEG monitoring group were significantly lower than in the clinical assessment group. The authors confirmed that EEG monitoring permitted more effective titration of propofol dosage for sedation during ERCP procedures and was associated with more rapidly patient recovery [16].
My previous study used the NarcotrendTM to guide the depth of sedation for ERCP procedure. NarcotrendTM monitoring was an effective tool for maintenance of the depth of sedation level in this procedure [17]. The other study compared the clinical efficacy of NarcotrendTM monitoring and clinical assessment used to provide deep sedation in patients who underwent ERCP procedure. In the study, Modified Observer’s Assessment of Alertness/Sedation scale 1 or 2 and the NarcotrendTM index 47-56 to 57-64 were maintained during the procedure. All endoscopies were completed successfully. Both NarcotrendTM and clinical-assessment-guided propofol deep sedation were equally safe and effective as well as demonstrated comparable propofol dose and recovery time. However, the NarcotrendTM-guided sedation showed lower hemodynamic changes and fewer complications compared with the clinical-assessment-guided sedation [18].
Esophagogastroduodenoscopy (EGD) is commonly performed by using topical pharyngeal anesthesia. Topical lidocaine is normally used as pretreatment for pharyngeal anesthesia. My previous study evaluated the clinical efficacy of topical viscous lidocaine solution and lidocaine spray when each was used as a single agent for unsedated EGD [19]. All patients were randomized into the viscous lidocaine (V) group (n = 930) or the lidocaine spray (S) group (n = 934). The results showed the procedure was successfully completed in 868 patients from group V and 931 patients from group S. Patient’s and endoscopist’s satisfaction, pain score, patient tolerance, and ease of intubation in group S were significantly better than those in group V. Additionally, adverse events in group S also occurred significantly lower than group V. This study demonstrated that the use of topical lidocaine spray was shown to be a better form of pharyngeal anesthesia than viscous lidocaine solution in unsedated EGD procedure [19].
Consequently, the use of posterior lingual lidocaine swab can apply for EGD procedure. Soweid and colleagues evaluated the effect of posterior lingual lidocaine swab in 80 patients who underwent diagnostic EGD procedures on patient tolerance, the ease of performance of EGD procedure, and to determine if such use would decrease the need for intravenous sedation [20]. The result of their study demonstrated that patients in the lidocaine swab group tolerated the procedure better than those in the lidocaine spray group. The procedural difficulty and the need of intravenous sedation in the lidocaine swab group were lower than in the lidocaine spray group. Additionally, the patients and the endoscopists in the lidocaine swab group were more satisfied than in the lidocaine spray group. They suggested the use of posterior lingual lidocaine swab for EGD procedure because of patient comfort and tolerance, endoscopist satisfaction, and reduction of the need for intravenous sedation.
Ramirez and coworkers also compared the effect of glossopharyngeal nerve block and topical anesthetic agent for EGD procedure [21]. The aim of the study was to evaluate the sedation, tolerance to the procedure, hemodynamic stability, and the adverse events. They performed a clinical trial in a total of 100 patients who underwent EGD procedures. All patients in both arms also received intravenous midazolam. The procedures were reported without discomfort in 48 patients (88%) in the glossopharyngeal nerve block group and 32 patients (64%) in the topical anesthetic group. There were no significant differences in the incidence of nausea and retching in both groups. The study confirmed that the use of glossopharyngeal nerve block provided greater patient comfort and tolerance as well as also diminished the need for sedation in EGD patients [21].
Sedation for GIE procedure can be safely and effectively performed with a multidrug regimen utilizing anesthesiologist or nonanesthetic personnel with appropriate monitoring. Currently, sedation practices for GIE procedures vary widely. The need for sedation is decided by the type of endoscopy, duration of procedure, degree of endoscopic difficulty, patient physical status, and physician’s preferences. However, the sedation regimen for GIE procedures is still varied. Benzodiazepines and opioids are commonly used by nonanesthetic personnel. In contrast, propofol in combination with opioids and/or benzodiazepines is usually used by anesthetic personnel.
The choice of anesthetic technique for GIE procedure depends on the patient and the type of procedure. General anesthesia is commonly utilized in patients with ASA physical status >III and patients with cardiorespiratory instability, as well as in long duration and complicated procedures. Traditionally, tracheal intubation is also performed when general anesthesia is used. An anesthesiologist usually uses balanced anesthesia technique including opioid, inhalation agent, and neuromuscular blocking drug. The majority of these anesthetic agents have short-acting and short-duration properties.
Target-controlled infusion (TCI) is a computer-controlled open-loop administration of anesthetic drugs. A continuous infusion technique uses a pharmacokinetic model to predict the patient plasma and effect site concentrations from the infusion design and allows the anesthesiologist to target a selected concentration. The device computes the appropriate infusion system to accomplish this concentration [22]. The TCI rapidly attains and maintains a predefined plasma or effect site concentration of the anesthetic drug. An appropriate target concentration for achieving the desired clinical endpoint is selected. The TCI delivery system performs better than the manual system. Presently, TCI devices for propofol administration are approved in several countries.
Mazanikov and colleagues compared TCI (initial targeted effect-site concentration 2 mcg/mL) with patient-controlled sedation (PCS) (single bolus 1 mL, lockout time set at zero) in 82 patients who underwent elective ERCP procedures. Alfentanil was supplemented if needed. All procedures were performed successfully. Mean consumption of propofol and the recovery time in the TCI group was significantly greater than in the PCS group. However, mean consumption of alfentanil in both groups was comparable. The authors concluded that there were no benefits of TCI over PCS for propofol administration in ERCP procedures [23].
Because of interindividual variability, new techniques of administration for sedation have been developed. Patient-controlled sedation (PCS) devices deliver a predefined bolus of intravenous drug during a defined time with or without a lockout interval. A prospective, randomized, controlled study compared the use of PCS with propofol and remifentanil and the anesthesiologist-administered propofol sedation for 80 elective ERCP patients. Sedation level was assessed every 5 min by using Ramsay and Gillham sedation scores. All ERCP patients were completely successful except two patients in the PCS group. Mean level of sedation and total propofol consumption in the PCS group were significantly lower than in the anesthesiologist-administered propofol group. However, patient and endoscopist satisfaction were equally high in both groups. The study confirmed that PCS with propofol and remifentanil was a safe and well-accepted sedation technique for ERCP patients [24].
Moreover, the use of PCS with propofol and remifentanil has been compared with fentanyl and midazolam for sedation in patients who underwent colonoscopy by Mandel and colleagues [25]. Their study demonstrated that time to sedation and the recovery time in the PCS with the propofol and remifentanil group were significantly shorter than in the PCS with the fentanyl and midazolam group. However, the perceptions of patients, nurses and endoscopists were comparable between the two groups.
Procedural sedation in cirrhotic patients is challenged. Titration of sedative and analgesic drugs is needed for an optimal sedation level. The use of PCS for sedation in these patients is an alternative technique. Although, dexmedetomidine is suggested for procedural sedation and reported effective for alcohol withdrawal, the efficacy of dexmedetomidine as a sole anesthetic agent is controversial. Mazanikov and coworkers evaluated 50 patients with chronic alcoholism scheduled for elective ERCP procedures. All patients in the PCS with propofol and alfentanil group were successfully sedated, and in 19 of 25 (76%) patients in the dexmedetomidine group. They also suggested that a loading dose of dexmedetomidine 1 mcg/kg over 10 min, followed by continuous intravenous infusion 0.7 mcg/kg/h was insufficient for the ERCP procedure. In addition, dexmedetomidine was also related with prolonged recovery [26].
The use of propofol for sedation in GIE procedures may allow for better quality of sedation and faster recovery. Computer-assisted personalized sedation system (CAPS) is based on the patient response to stimulation and physiologic profiles. It presents an attractive means of delivering safe and effective doses of propofol. The closed-loop target-controlled system or continuous EEG recordings are used to assess the degree of sedation. Patient-controlled platforms may also be used. These devices may help physicians titrating propofol administration and controlling the physiological functions [27].
The SEDASYS System is a CAPS integrating propofol delivery with patient monitoring to allow physicians to safely administer propofol. The efficacy and safety of this system for sedation during GIE procedures was evaluated and compared with the combination of benzodiazepine and opioid in 1000 adult patients with ASA physical status class I-III. All patients were sedated in mild to moderate depth of sedation level. The study demonstrated that SEDASYS system was safe and effective for sedation during EGD and colonoscopic procedures. Additionally, patient and physician satisfaction as well as recovery time in the SEDASYS group were significantly better than patients in the combination of benzodiazepine and opioid group [28].
The use of inadequate sedative agents results in over and under depth of sedation. The use of CAPS for administration of propofol by nonanesthetic personnel achieving mild to moderate sedation in patients who underwent GIE procedures was evaluated by Pambianco and coworkers [29]. This study showed that propofol administration in mild or moderate sedation level by nonanesthetic personnel used with CAPS system in patients who underwent EGD and colonoscopic procedures was safe and effective. Moreover, low propofol dosage and short recovery time were noted.
Closed-loop administration of anesthesia systems can provide anesthesia automatically and its effect feedback controlled. This system contains a central system, a target control device such as syringe pump, vaporizer, and other drug delivery systems [30]. Currently, there are several closed-loop administration systems for neuromuscular blockade, depth of anesthesia, and pain control during decreased levels of consciousness. In addition, McSleepy is also a closed-loop control system that displays the patient’s depth of consciousness, muscular movement during surgery, and the level of pain [30].
Teleanesthesia is the use of telemedicine technology in anesthetic management including preoperative assessment at distance, video consultation, and performing anesthesia in remote locations where experienced anesthesiologists are not always present [30, 31]. The impact of telemedicine pre-anesthesia evaluation on periprocedural processes was confirmed by Applegate II and colleagues. Their study demonstrated that telemedicine pre-anesthesia evaluation offered patients time- and cost-saving benefits without more surgical delay. Moreover, telemedicine and in-person assessments were comparable, with high patient and physician satisfaction [32].
Generally, lidocaine is the most common local anesthetic agent used for GIE procedure. The viscous lidocaine solution and lidocaine spray are usually performed for upper GIE procedure. In addition, lidocaine gel or jelly is frequently employed for lower GIE procedure. Recently, lidocaine lozenge has been tried to use for EGD procedure. Mogensen and colleagues evaluated the effect and acceptance of a lidocaine lozenge compared with a lidocaine viscous oral solution as pharyngeal anesthesia before EGD [33]. The 110 adult patients were randomized to receive either 100 mg lidocaine as a lozenge or 5 mL lidocaine viscous solution 2%. Supplemental intravenous midazolam was administered if needed. They concluded that the lozenge could reduce gag reflex and patients’ discomfort, and improved patients’ acceptance during the procedure. In addition, the lozenge form had also a good taste [33]. Another study of the lidocaine lozenge used for pharyngeal anesthesia in EGD procedure has been reported by Tumminakatte and Nagaraj [34]. The authors compared the efficacy, safety, and patient comfort for the lidocaine lozenge and lidocaine viscous as a single agent before EGD procedure. This study showed that lidocaine lozenge was effective and safe for pharyngeal anesthesia before EGD procedure. It was relatively better than lidocaine viscous in terms of lesser discomfort and procedural difficulty as well as increased tolerability of the EGD procedure [34].
Moreover, topical bupivacaine could be used as pretreatment for pharyngeal anesthesia in unsedated EGD. The effect of a bupivacaine lozenge as pharyngeal anesthesia and a lidocaine spray before EGD was assessed by Salale and coworkers [35]. Ninety-nine adult patients were randomized to receive either a bupivacaine lozenge or lidocaine spray. Patient discomfort and the acceptance of gag reflex during EGD procedures were evaluated. The results showed that patient discomfort and gag reflex during procedure in the bupivacaine lozenge group were significantly lower than the lidocaine spray group. The authors also suggested that bupivacaine lozenge for topical pharyngeal anesthesia before an unsedated EGD procedure verified to be a superior option as compared with lidocaine spray [35].
Chan and colleagues studied the effectiveness of 10% lidocaine pump spray plus plain Strepsils and Strepsils anesthetic lozenge plus distilled water spray for EGD procedure in terms of patient tolerance, taste of anesthetic agent, intensity of numbness, amount of cough or gag, and the degree of discomfort at esophageal intubation. They concluded that topical lidocaine spray was superior to the flavored anesthetic lozenge as a topical pharyngeal anesthesia in unsedated EGD procedure [36]. Furthermore, the safety and efficacy of a lidocaine lollipop as single-agent anesthesia for EGD has been evaluated by Ayoub and coworkers [37]. The main outcome variables of the study were the success rate and safety of local anesthesia by using lidocaine lollipop in addition to the need for intravenous sedation. Their study showed that lidocaine lollipop, a favorable form of pharyngeal anesthesia, was safe and well tolerated for EGD procedure.
Midazolam is one of the most common drugs used for sedation during GIE procedures. It is a rapid-onset, short duration of action, and water-soluble benzodiazepine with anxiolytic, amnesic, sedative, muscle relaxant, and anticonvulsant properties. These actions are due to the effect of binding to gamma-amino butyric acid receptors in the central nervous system. Midazolam has few adverse effects. Respiratory depression is the most important adverse effect and is synergistic when used in combination with opioids. The standard dose in adult patients is 0.015-0.06 mg/kg [38].
Fentanyl is a potent synthetic opioid and also commonly used for GIE procedures. It has a rapid onset, short duration of action, and lack of direct myocardial depressant effects. The onset of action is 30–60 s, and the duration of action is 30–45 min. Generally, the dose for GIE procedure is usually 1–2 mcg/kg, with a maximum dose of 100–150 mcg in adult healthy patients. Because of its analgesic effect, fentanyl is commonly used for therapeutic GIE procedures. Of late, the combination of fentanyl and midazolam is an accepted regimen with a safety profile [39-41]. However, fentanyl can cause respiratory depression including apnea as well as nausea and vomiting. It can reduce the heart rate.
Remifentanil is a fentanyl analog with a methyl ester group and is hydrolyzed by plasma and tissue esterases. Its metabolism is not affected by genetics, age, hepatic failure, and renal failure. Its action is rapid. The use of remifentanil for sedation in GIE procedures is not entirely recognized. Remifentanil is generally performed by using the continuous infusion technique. The TCI of remifentanil is another preference. The combination of propofol and remifentanil for sedation in GIE procedures is usually used. The study of Abu-Shahwan and Mack demonstrated the efficacy and safety of a combination of propofol and remifentanil for deep sedation in children who underwent GIE procedures [42]. In their study, anesthesia was induced with sevoflurane and nitrous oxide in oxygen, and was maintained with infusion of propofol and remifentanil. All GIE procedures were successfully completed with no complications. However, this combination of propofol and remifentanil demonstrated the reduction of heart rate, blood pressure, and respiratory rate.
Remifentanil in TCI appears to be a satisfactory drug for sedation in GIE procedures. However, propofol in TCI for GIE procedures demonstrates better sedation than remifentanil in TCI. This issue was confirmed by Munoz and colleagues [43]. They compared remifentanil and propofol in TCI for sedation in 69 patients during GIE procedures. The authors concluded that propofol in TCI for sedation in patients who underwent GIE procedures seemed to be an adequate agent. Additionally, propofol in TCI created less adverse effects and higher patient satisfaction than remifentanil in TCI.
Remimazolam is a rapidly acting intravenous sedative drug. It combines the properties of midazolam and remifentanil. Additionally, its tendency to cause apnea is very low. Remimazolam has potential to be used as a sedative drug in the intensive care unit and as a novel agent for procedural sedation [44, 45]. Recently, remimazolam was evaluated for sedation in patients who underwent upper GIE procedures by Rogers and McDowell. This clinical trial demonstrated that the time to recovery from sedation of remimazolam was faster and more reliable than midazolam [46]. Moreover, Worthington and colleagues assessed the feasibility of remimazolam for sedation during colonoscopy and reversing the sedative effects of remimazolam with flumazenil in 15 healthy volunteers. The sedation for colonoscopy was successfully completed in more than 70% of subjects. In addition, all subjects rapidly reversed with flumazenil and also rapidly recovered within 10 min. No serious adverse events were observed [47].
Propofol has sedative, hypnotic, and anesthetic properties. However, it does not have analgesic effects. Propofol rapidly crosses the blood–brain barrier. The onset of action is 30–60 s. Dose reduction is needed in patients with cardiac dysfunction and in elderly patients. However, the dose reduction of propofol in patients with moderately severe liver disease or renal failure is not required. Propofol potentiates the effects of analgesic and sedative drugs. The advantage of propofol has been demonstrated for therapeutic GIE procedures and not for diagnostic GIE procedures.
Propofol in combination with opioid or benzodiazepine can cause significant cardiovascular depression and may result in a deeper than expected depth of sedation because of its narrow therapeutic window. Pain at the injection site is the most frequent local complication. Several methods for propofol delivery have been used for GIE procedures. Generally, propofol is administered intravenously as a repeated bolus injection, continuous infusion, or a mixture of both. Currently, the nonanesthesiologist-administered propofol is a controversial issue and also varies among countries.
Generally, propofol is usually used for various GIE procedures. A previous study confirmed that sedation with propofol alone or propofol combined with fentanyl or midazolam in children was safe and effective. However, the use of propofol alone provides lesser sedation and ease of endoscopy than the use of propofol in combination with fentanyl or midazolam [48]. In Siriraj GI Endoscopy Center, the combination of propofol, fentanyl, and/or midazolam was usually used for GIE procedures even in pediatric patients. Moreover, our previous studies also demonstrated the clinical effectiveness of an anesthesiologist-administered sedation outside of the operating room for pediatric GIE procedures. Although, all sedation-related complications were relatively high, all of these complications were transient and easily treated [39, 40, 49, 50]. In terms of procedure-related complications, propofol-based sedation does not increase the rate of colonoscopic perforation [51].
For invasive GIE procedures, propofol-based sedation for ERCP and percutaneous endoscopic gastrostomy procedures in sick and elderly patients by anesthetic personnel with appropriate monitoring was also safe and effective without any serious complications [52-54]. The safety of propofol sedation for EUS with fine needle aspiration procedure was confirmed by Pagano and coworkers [55]. The complication rates for propofol deep sedation and meperidine/midazolam administered for moderate sedation were not significantly different. Furthermore, propofol combined with fentanyl and midazolam is frequently used for GIE procedures including EUS and small bowel enteroscopy [56-60].
Several guidelines do not recommend the use of propofol for routine GIE procedures. The safety and efficacy of propofol administered by registered nurses has been reported in a case series including 2000 patients undergoing elective EGD and/or colonoscopy [61]. Another study demonstrated that trained nurse-administered propofol for GIE sedation in patients with ASA class I, II, and III was safe and effective. The anesthetic support was assisted in 11 patients (0.4%) [62].
Similar to qualified nurses, the gastroenterologist can administer propofol effectively. Several guidelines recommend that gastroenterologist-administered propofol should be used to sedate patients only at mild or moderate sedation levels. Additionally, the patients must have ASA physical status not more than III. The study of Vargo and colleagues confirmed that gastroenterologist-administered propofol for elective ERCP and EUS procedures resulted in the reduction of propofol dosage and the improvement of recovery activity as well as the rapid detection of respiratory depression. This study also demonstrated that gastroenterologist-administered propofol should be a cost-effective sedation technique [63].
Propofol is commonly used by anesthesiologists for anesthesia in GIE procedures. To date, the use of propofol is still controversial. Propofol can be used by well-trained registered nurses or physicians in some countries. However, in developing countries, propofol-based sedation is performed by anesthesiologists or anesthetic nurses. Berzin and coworkers accomplished a cohort study of sedation-related adverse events, patient- and procedure-related risk factors associated with sedation, as well as endoscopist and patient satisfaction with anesthesiologist-administered sedation in 528 patients who underwent ERCP procedures. The study confirmed that anesthesiologist-administered sedation for ERCP patients was safe and effective. Cardiorespiratory-related adverse events were generally minimal [64].
Fospropofol is a water-soluble prodrug of propofol that is currently approved for sedation for diagnostic and therapeutic procedures. It is characterized by a smooth and predictable rise and decline rapidly observed following intravenous administration. It does not cause pain on intravenous injection, but it has been associated with paresthesia in the perineal and perianal area. However, fospropofol causes dose-dependent hypotension, respiratory depression, and apnea. Generally, a standard of fospropofol sedation is 6.5 mg/kg. In high-risk and elderly patients, a lower dose should be administered. Bergese and coworkers compared the efficacy and safety of fospropofol in a dose of 4.875 mg/kg and 6.5 mg/kg for sedation in high-risk elderly patients who underwent colonoscopy. This study showed that fospropofol in a dose of 4.875 mg/kg for sedation in high-risk elderly patients who underwent colonoscopy was not a clinically significant advantage. Fospropofol in a dose of 6.5 mg/kg was recommended in the elderly, obese, and high-risk patients when used for moderate sedation [65].
Ketofol is the combination of ketamine and propofol in various concentrations. It isan agent of choice for a variety of GIE procedures. Ketamine, a neuroleptic anesthetic agent, works on thalamocortical and limbic N-methyl-D-aspartate receptors. Ketamine stimulates the cardiorespiratory system. A direct effect increases cardiac output, arterial blood pressure, heart rate, and central venous pressures [66]. In contrast, propofol has antiemetic, anxiolytic, hypnotic, and anesthetic properties. Additionally, propofol has a short recovery time without an increase of cardiorespiratory side effects. As a result, the combination of these two drugs has several benefits because of hemodynamic stability, lack of respiratory depression, good recovery and post-procedural analgesia. The safety and efficacy of ketofol as a sedoanalgesic agent are dependent on the dose and the ratio of the mixture [67].
Ketofol is also commonly used for sedation during GIE procedures. My previous study evaluated the clinical efficacy of the ketofol and propofol alone when each regimen is used as sedative agents for colonoscopic procedure. A 194 patients were randomized into two groups; 97 patients in group PK received propofol and ketamine and 97 patients in group P received propofol and normal saline for sedation. All patients were premedicated with 0.02–0.03 mg/kg of midazolam. All colonoscopic procedures were completely successful. There were no significant differences in patient tolerance, hemodynamic parameters, recovery activity, patient and endoscopist satisfaction, as well as the sedation-related adverse events between the two groups. In addition, these adverse events were transient and mild in degree [68].
Dexmedetomidine is a specific central alpha-2 adrenoreceptor agonist with sedative and analgesic properties. Dexmedetomidine has no effect at the GABA receptor, and is not associated with significant respiratory depression. The patients can be sedated but are able to be awakened to full consciousness easily. It induces a biphasic blood pressure response: high doses cause hypertension, and lower doses cause hypotension and bradycardia. The other disadvantages of dexmedetomidine include a slow onset and longer duration of action [42].
To date, the role of dexmedetomidine for GIE procedures is not entirely established and remains a controversial issue. Samson and colleagues compared the sedation efficacy and the hemodynamic effects of dexmedetomidine, midazolam, and propofol in 90 patients with ASA physical status I or II, who underwent elective diagnostic upper GIE procedures. The results demonstrated that endoscopist satisfaction level, recovery, and the hemodynamic stability in the dexmedetomidine group were significantly better than in the midazolam and the propofol groups [69]. However, dexmedetomidine alone is less effective than the combination of propofol and fentanyl for moderate sedation during ERCP procedure [70]. Most of the patients needed supplementary analgesic and sedative drugs to accomplish the depth of sedation level. However, these findings do not allow us to conclude that propofol alone is better than dexmedetomidine alone, because the conclusion was established for propofol combined with fentanyl. Moreover, dexmedetomidine was associated with higher hemodynamic instability and a prolonged recovery phase [70].
Ketamine is a dissociative anesthetic agent and works on thalamocortical and limbic N-methyl-D-aspartate (NMDA) receptors. Its actions are described by catalepsy in which eyes remain open and there is slow nystagmic gaze while corneal and light reflexes remain intact. Direct effects increase cardiac output, blood pressure, heart rate as well as pulmonary arterial and central venous pressures, which stimulates the cardiorespiratory system. However, ketamine produces unpleasant psychological effects including hallucinations, nightmares, and emergence reactions. Dexmedetomidine is a specific central alpha-2 adrenergic agonist that decreases central presynaptic catecholamine release. It has no effect at the GABA receptor, and is not associated with significant respiratory depression. Its properties of sedation, anxiolysis, and analgesia together with its beneficial pharmacokinetics make it a valuable adjunct for procedural and intensive care sedation [66].
The use of ketodex for GIE procedures was reported by Goyal and colleagues [71]. They used a bolus dose of ketamine 2 mg/kg and dexmedetomidine 1 mcg/kg for upper GIE procedures in pediatric patients. The results of the study showed that blood pressure, heart rate, and oxygen saturation did not change significantly from the baseline. The airway interventions were not used. In addition, there were also no laryngospasm and postprocedural shivering. The delirium score was lower than 4 in all patients except for two cases. This case series supported the use of ketodex was safe and clinically effective for upper GIE procedure in pediatric patients [71].
Cisatracurium, an isomer of atracurium, is about three times more potent than atracurium and less tendency to release histamine than atracurium. It experiences spontaneous degradation at physiological pH and temperature by Hofmann elimination. Liver disease does not appear to have an effect on cisatracurium. Pharmacokinetics and pharmacodynamics of cisatracurium in normal adult and liver transplant patients do not show clinically significant differences in the recovery profiles [72]. Because of its beneficial properties, cisatracurium is a muscle relaxant drug of choice for tracheal intubation and maintenance during general anesthesia in GIE procedures [50, 59].
Rocuronium is a steroidal nondepolarizing neuromuscular blocking drug and has a rapid onset of action. It is a muscle relaxant drug of choice for tracheal intubation and maintenance during general anesthesia in GIE procedures [50, 59, 73]. Rocuronium has emerged as an alternative to succinylcholine for facilitating rapid tracheal intubation in full stomach patients. It is predominantly useful as a relaxant agent for tracheal intubation in patients at risk of hyperkalemia and patients with known or suspected increased intracranial or intraocular pressure. However, rocuronium may be used cautiously in patients with impaired liver function [74].
Naloxone is a pure mu-opioid antagonist with a high affinity for the receptor. It can reverse both the analgesic and respiratory effects of opioids [4, 42]. The standard dosage of intravenous naloxone is 1–2 mcg/kg with a maximum dose of 0.1 mg/kg and up to 2 mg. However, naloxone has a short duration of action and one dose typically only lasts for 30–45 min. Patients should be monitored for at least 2 h after the last dose of naloxone. The adverse reactions of naloxone include reversal of opioid withdrawal, nausea/vomiting, hypertension, tachycardia, pulmonary edema, and cardiac dysrhythmias.
Flumazenil is a benzodiazepine antagonist. It is a highly specific benzodiazepine receptor antagonist and can safely reverse the sedative and respiratory effects caused by benzodiazepines. The adult dose is 0.01 mg/kg and up to 1 mg. Its duration of action is just about 1 h. However, this effect is reversible. Importantly, the patients should be observed for at least 2 h after the administration of flumazenil [4, 42]. The adverse reactions of flumazenil consist of sweating, flushing, nausea/vomiting, hiccup, agitation, abnormal vision, paresthesia, and seizure.
Sugammadex is a selective relaxant binding drug that quickly reverses the effects of aminosteroid neuromuscular blocking agents such as rocuronium and vecuronium. It was successfully used to reverse rocuronium-induced neuromuscular block in patients where neostigmine was insufficient. Dogan and colleagues investigated the efficacy of sugammadex after unsatisfactory decurarization following neostigmine administration. This study was performed on 14 patients who experienced inadequate decurarization (TOF < 0.9) with neostigmine after general anesthesia. A dose of 2 mg/kg of sugammadex was used. The result confirmed that sugammadex was successfully performed to reverse rocuronium-induced neuromuscular block in patients where neostigmine was insufficient [75]. The capability to reverse a rocuronium-induced neuromuscular block at any stage and possibly to improve patients’ safety might make sugammadex a very attractive drug for the use in day-case anesthesia.
Another study compared the efficacy of sugammadex and neostigmine for the reversal of vecuronium-induced neuromuscular blockade in elective surgical patients [76]. All patients, ASA physical status I-III obtained a dose of 0.1 mg/kg vecuronium for tracheal intubation and maintenance dose of 0.02–0.03 mg/kg if needed. Neuromuscular blockade was monitored by using acceleromyography. At the end of surgery, patients were randomized to receive either sugammadex 2 mg/kg or neostigmine 50 mcg/kg and glycopyrrolate 10 mcg/kg. The study showed that mean recovery times to a TOF ratio of 0.8 and 0.7 in the sugammadex group were significantly shorter than in the neostigmine group. No serious adverse events were noted. The authors concluded that sugammadex presented significantly quicker reversal of vecuronium-induced neuromuscular blockade compared with neostigmine [76].
Sevoflurane is an inhalation agent with ideal properties for deep sedation during GIE procedures in pediatric patients. In addition, it is commonly used for balanced general anesthesia. A retrospective study reviewed data from children receiving sevoflurane inhalation administered by an anesthesiologist via laryngeal insufflation to attain deep sedation for outpatient GIE procedures. All patients were adequately sedated with sevoflurane, and no intravenous line was needed. Time to awakening, discharge, and complication rate in the sevoflurane group were significantly lower than in the combination of midazolam, fentanyl, and ketamine, as well as in the propofol alone groups. This report suggested that deep sedation with sevoflurane insufflation for pediatric outpatient GIE procedure is as safe as conventional sedation techniques [77].
Consequently, Meretoja and colleagues compared anesthesia with sevoflurane or halothane for bronchoscopy or gastroscopy, or both in 120 infants and children. All pediatric patients were assigned to receive either 7% sevoflurane or 3% halothane in 66% nitrous oxide in oxygen for induction of anesthesia. Induction time and psychomotor recovery as well as the incidence of nausea/vomiting and cardiac arrhythmia in the sevoflurane group were significantly lower than in the halothane group. This study confirmed that the use of sevoflurane was better than the use of halothane for bronchoscopy and gastroscopy procedures in pediatric patients [78].
Desflurane is an ether inhalational anesthetic agent. It offers the advantage of precise control over depth of anesthesia along with a rapid, predictable, and clear-headed recovery with minimal postoperative adverse events. It also has advantages when used in extremes of age and in obese patients. Desflurane is generally used for the maintenance of balanced general anesthesia because of its rapid recovery. Currently, the use of desflurane may increase the direct costs of anesthetic care [79]. However, no significant differences were demonstrated between desflurane and sevoflurane in the late recovery period.
Blood pressure, heart rate, respiratory rate, oxygen saturation, and level of consciousness are monitored and documented at least every 15 min or less, for a minimum of 30 min after the last dose of sedation drug. These parameters should be monitored and noted in the recovery period. Moreover, the patients should be monitored for at least 2 h after the last dose of a reversal drug. All patients will be discharged from the recovery room once the discharge criteria are completed. Generally, the majority of sedated patients would complete an acceptable score on or before 1 h after GIE procedure. Most delays after satisfactory scores were due to nonmedical causes [80]. In ambulatory cases, the presence of an escort must be confirmed, and the patients should not drive for at least 24 h.
GIE procedure requires some forms of anesthesia. To date, sedation for GIE procedure can be effectively and safely performed by anesthesiologist or nonanesthetic personnel with appropriate patient selection and monitoring. The new anesthetic drugs and monitoring equipments for safety and efficacy are available. However, pre-anesthetic evaluation and preparation, anesthetic drugs used, monitoring practices and post-anesthesia management are still essential for the anesthesia innovations in GIE procedures.
It seems people everywhere are questioning the ability of traditional political actors to represent their interests and are increasingly seeking a more direct and unmediated relations to the decisions that affect their lives [1]. The Southern Cameroon-Ambazonia crisis commonly known as the Anglophone crisis revolves around the marginalization of the Anglophones and the dilution of their cultural identities especially concerning education and the judiciary by the Francophones in their attempt to assimilate them. Anglophones have therefore collectively given voice to their grievances and concerns and are demanding that something be done about them and they have taken extra-institutional actions by arming themselves to defend themselves against the government security forces who abuse their human rights by arbitrarily arresting, torturing, detaining, killing them, burning their houses, raping their women and also refusing them the right to self-determination.
The collective challenge that from the onset of the crisis was predominantly regressive, that is, a return to federation as it was from 1961 to 1972, changed due to Cameroon government’s failure to listen to their plights. They overwhelmingly became progressive, that is, they wanted absolute independence except for their elite (parliamentarians, ministers and other prominent government workers) still clamoring for federation and a unitary state because they benefitted from the government and were afraid of losing their jobs. The question we ask is: how have Anglophones historically sustained social solidarity with their common opponent, which is the government of Cameroon, in order to attain their desired policy change? What means have they used to make their voices heard in the international scene? And finally, how have the government responded to their protest?
The rise and spread of new ICTs have transformed the way that society is organized, which of course include social movements. Internets and SMS messaging for examples have enabled activists to coordinate protest in record time, giving rise to the ‘flash mob’ phenomenon. ‘Flash mob’ is a term that originally referred to social experiments and countercultural movements to reclaim ‘public spaces’ Salmond [2]. The Anglophone movement can be dubbed as the ‘Twitter Revolution’ or ‘Facebook Revolution’ emphasizing the role of social media in diffusing videos of human rights abuses and to organize protest mobilizations both at the local and international levels.
The videos were diffused all over the world thereby creating huge impact in the international community. Diffusion is the process through which movements import and export ideas, tactics, strategies, organizational forms and cultural practices as Entman [3] puts it, by framing: a way of selecting and highlighting a particular claim to mobilize supporters, demobilize antagonists and convince observers of the worthiness of their course. The frame Ambazonian highlight is that their union with Francophone is fake and it never took place because there is no certificate of union and that they are culturally different, therefore the need for the restoration of their independence. Their frames are deeply rooted in local or national political and cultural context and are more open to diffusion especially as it concerns the abuse of human rights. They use a frame that makes them to think globally and act locally, that is, they take a political action frame that links global problems with local action.
Many videos have been spread on the brutality of the security forces that disrespected the universal declaration of human rights. They can easily be downloaded from the Internet clearly showing that due to the age of Twitter and Facebook revolution, the images have been globalized in order to gain international attention from organizations and countries that matter in the world. The spreading of these videos and other information led to the shutting down of the Internet in Ambazonia for 93 days.
The objective of this work is to collect and analyze short videos and journalists’ reports for television stations using social movement theory.
The Ambazonia crisis is an attempt of Southern Cameroonians to break the dominant Francophone cultural hegemony. Since 1972, La République du Cameroun has dominated the Southern Cameroonians, which came into union with them from a weaker position with a population numerically smaller. As a result, La République du Cameroon has been making efforts not just to dominate them but to absorb them into the broader Francophone cultural system. They silently destroyed the dignity and statehood of Anglophones-not by the French-speaking community at large, but by the government which was led and dominated by Francophones.
Marx and Engels [4] famously argued that, in any epoch, the dominant ideas are the ruling ideas in society that serve to maintain the dominance of the ruling classes. Those who have the means of economic production also have control over the production of ideas, and the class which is the material force of society is at the same time the ruling intellectual force. The ruling class, rules also as thinkers and as producers of ideas and regulate the production and distribution of ideas of their age. Similarly, La République du Cameroon has been producing ideas to suppress Southern Cameroonians because of their dominance over the economy, judiciary and political institutions. When the crisis started in order to dilute it, they produced many unsuccessful concepts such as the promotion of Bilingualism and multiculturalism, the national disarmament and demobilization and reintegration committee all headed by Anglophones and whose reports were dropped in the dustbins. Finally, they gave Anglophones what they termed ‘Special Status,’ which Anglophones rubbished as being empty. How did these two separate entities come together and form a union?
Cameroon was initially a German’s territory from 1887 to 1914 before the British invaded it from Nigeria in 1914 and the German surrendered in February 1916. After the war, the League of Nations partitioned the colony between the United Kingdom and France on June 28, 1919, and France gained the larger geographical share. French Cameroon became independent as La République du Cameroun in January 1960 and Nigeria was scheduled for independence later that same year, which raised question of what to do with the British territory. A plebiscite was agreed on and it was held on February 11, 1961, and the British Southern Cameroon voted to join Cameroon as West Cameroon I.CB Dear [5]. To negotiate the terms of the union, the Foumban Conference was held on July 16–21, 1961 in which the Federal Constitution was drafted. It stated in Article 47.1 that “No bill to amend the constitution may be introduced if it tends to impair the unity and integrity of the federation.”
This poorly conducted re-unification was based on centralization and assimilation, and has led the Anglophone minority feeling politically and economically marginalized as their cultural differences are ignored. “On the 1st September 1966 the Cameroon National Union (CNU) was created by the union of political parties of East and West Cameroon. Most decisions were taken without consultation, which led to widespread feelings amongst the West Cameroonian public that although they voted for reunification, La Republique du Cameroon was absorbing or dominating them,” Wikipedia [6].
Achankeng [7] states that although the plebiscite was an expression of willingness to associate with French Cameroon, no necessary discussions took place to arrive at an agreed document and set the legal basis of the federation. So it never took place and neither were any agreements subsequently signed between the two countries.
In 1972, President Ahidjo (the President of the Republic of Cameroon) conducted a referendum on the form of the state. Although the West Cameroon lawmakers heavily opposed and rejected it on the ground that it was a violation of the 1961 Federal Constitution, he went ahead with the referendum and the Federal Republic of Cameroon became the United Republic of Cameroon [8]. All these events were calculated attempts meant to incorporate a former colony into another state. Bongfen [9] and Ajong [10] state that it abolished “all federal legislative, judicial and administrative institutions, and removed all guarantees that protected the rights of the minority Southern Cameroonians in the federation. Unlike during the plebiscite of 1961 wherein only Southern Cameroonians voted to decide on their destiny, the May 1972 referendum was extended to all the people of la République du Cameroun. It was ‘a creeping annexation than unification’. However, the dissenting voices of Southern Cameroonians rejecting the centralized United Republic of Cameroon were dwarfed by the wide majority of La République. Many Southern Cameroonians regard 20th May, - the national day of today’s Cameroon – as a day when they lost their freedom”.
In 1984, Paul Biya removed one of the stars from the flag and changed the official name of the country to the Republic of Cameroon (La République du Cameroon), which Cameroon had before her unification with Southern Cameroon. Some Anglophones such as Gorji-Dinka, Bernard Fonlon and Carlson Anyangwe from the Southern Cameroon considered it as the dissolution of the 1961 union.
Citizens from these regions, that is, the Anglophone regions, have been mobilizing against their marginalization by the Francophone-dominated government. They complain about chronic under-representation in all issues of national life, including political appointments and professional training. They argue that since their reunification, they have been treated as second-class citizens. Their vibrant economic and political institutions have been completely erased, and their education and judicial systems have being undermined and degraded.
Gorji Dinka and Albert Mukong: Southern Cameroonian nationalists who protested the ill-treatment of their people by the central regime were arrested and detained. Representatives of southern Cameroonians in the tripartite talks of 1991 proposed a return to the federation, but the leaders of La République du Cameroon ignored them. In 1994, John Ngu Focha and Salomon T. Muna both former Prime Ministers of the Southern Cameroons returned to the United Nations in New York and demanded separate independence for the Southern Cameroons. The mission to the UN preceded the All Anglophone Conference (AAC 1), which took place in Buea in April 1993 bringing together all Southern Cameroon citizens who unanimously called for the restoration of the statehood of the Southern Cameroons. A second All Anglophone Conference (AAC 2) was held in Bamenda in May 1994, at which the decisions of AAC 1 were reiterated and a reasonable time was given to French Cameroon to accept a return to the two state federations or Southern Cameroon would revive its statehood and independence. The implementation of AAC 1 and AAC 2 was however stalled by the brutal arrests and incarceration of the leaders of the AAC with several others escaping into exile.
The ACC was renamed the Southern Cameroons Peoples Conference (SCPC), and later the Southern Cameroon People’s organization (SCAPO), with the Southern Cameroon National Council (SCNC) as the executive governing body. Southern Cameroon National Council younger activists formed the Southern Cameroons Youth League (SCYL) in Buea on May 28, 1995.
When they felt their demands were met with contempt and total disregard, the SCNC took their case back to the United Nations led by John Foncha and protested against La République du Cameroun annexation of their territory. Their focus has been maintained on the restoration of the statehood of Southern Cameroon, and the government brutal repression has helped to unify them.
Police routinely disrupted SCNC activities: On March 23, 1997, gendarmes killed about 10 people in a raid in Bamenda. The police arrested between 200 and 300 people, mostly SCNC supporters as well as members of the Social Democratic Front. In the subsequent trials, Amnesty International and SCNC found substantive evidence of the government torturing and using force on them. The raid and trial resulted in a shutdown of SCNC activities. On October 1, 1999, SCNC militants took over Radio Buea to proclaim the independence of Southern Cameroon but failed to do so before security forces intervened. After clashes with the police, the SCNC was officially declared illegal by the Cameroonian authorities in 2001. In 2006, a faction of SCNC once again declared the independence of Ambazonia Lansdorf, ed. [11].
Although Cameroon is bound by the international law and its own constitution to respect human rights and freedoms, many human rights have been violated in Southern Cameroon. This work pays particular attention on the cruel treatment of people who exercise the right to association and peaceful assembly. We use videos to show how these rights were violated in Ambazonia. We argue that the videos helped to globalize the crisis and attract the attention of the international community to the severity of the killings and abuse.
In the age of smartphones, images or video-making has become less problematic as most people even in the third world possess a smartphone with a built-in camera. They take pictures of what is relevant to them in their daily lives. They usually film the remarkable, the extraordinary, the exceptional and not the ordinary or everyday activities [12]. From the onset of the Anglophone crisis, participants made many videos to expose the human right abuses of the military and they flooded the Internet. That was why the government cut-off the Internet in the English-speaking areas to stop them from circulating incriminating images.
We decided then to collect 30 videos to analyze them because they provide information that cannot be provided by other types of data. They are used as ‘proofs of facts’ and as it is often said, a picture or video is more, and different, than a thousand words because they contain much more visual information on bodily movement and include acoustic data. Although images are specific reality constructions, ambivalent, subjective and diffuse, their interpretation must be substantiated in words [13].
The videos collection contribute toward answering a research question and are interpreted by providing verbal accounts and linked to the theoretical concept of cultural dominance and media and information communication. The questions we asked concerning each of the videos were similar to those asked by Becker [14]: What are the acts of violence and human rights abuses in each video? How can they be interpreted and linked to our theoretical concept? What insight do they generate and substantiate? What different kinds of people are there? We link observations to theoretical concepts such as status, groups, norms, rules, and common understandings, deviance and rule violation, sanctions and conflict resolution.
The relationship that exists between Southern Cameroon and La République du Cameroon is one of two people, two inheritances, and two divergent mentalities: one struggles for its liberation, while the other suppresses and abuses its human rights or struggles to maintain control over it by using its mighty state military. They speak different languages with little or no rapprochement although they live in the same country. The various videos below clearly show the differences. The oppressors’ troops speak in French, while the oppressed speaks in Pidgin English. A country divided predominantly by language although language is not the cause of the Anglophone crisis: it is the history of people. This shows the struggle between the two people and languages while one is resisting the onslaught and domination, the other is trying very hard to overcome and crush them. Having been oppressed for long, the oppressed is not willing to give up and the oppressor is not willing to let her leave her unitary state, and then the struggle of two people stiffens. The government that has been in power for over 38 years does everything to suppress the uprising by sending its brutal security forces to harass the Anglophones who are striking for a just course.
According to Cameroon Concord News 2019 [15], “being Anglophone or francophone in Cameroon is not just the ability to speak, read and use English or French as a working language. It is about belonging to the Anglophone or Francophone ways including things like outlook, culture and how local governments are run. Anglophones have long complained that their language and culture are marginalized”. They thought it necessary to protect their judicial, educational and local government systems. They wanted an end to annexation and assimilation and more respect from government for their language and political philosophies. They preferred a total separation by creating their own independent state if the government failed to listen to them.
According to
They decided to express their grievances by protesting. The protests began in the streets of Anglophone cities as thousands of Anglophone Cameroonians, from lawyers and teachers as well as irate youth, protested against the Francophone hegemony. Handfuls of videos show young men manifesting determination and strength for change in the Southern Cameroon-Ambazonia. They collaborated especially when one of them was shot because they were conscious of their marginalization. They knew the police would shoot them but they moved on. This shows that a disillusioned unemployed youth is very dangerous for the health of a country. They all hungered for independence and not even federalism that some elite would talk of. Although largely, but not always peaceful in nature, these protests were met with sustained repressions from the Cameroon authority and security forces. Some peaceful protesters were killed during the demonstrations; hundreds of people were arrested and detained without trial. Our objective in this work is to analyze the confrontation between the protesters and security forces using amateur videos secretly taken by the protesters.
The protest began on October 6, 2016, as a sit-down strike initiated by the Cameroon Anglophone Civil Society Consortium (CACSC), an organization consisting of lawyer and teacher trade unions from the Anglophone regions of Cameroon. Barrister Agbor Balla, Dr. Fontem Neba and Tassang Wilfred led the strike.
According to Wikipedia [17], “the common lawyers of Anglophone Cameroon were said to have written an appeal letter to the government over the use of French in schools and courtrooms in the English-speaking regions of Cameroon. In an effort to protect the English culture, they began a sit-down strike in all courtrooms on October 6, 2016. Peaceful marches began with marches in the cities of Bamenda, Buea, and Limbe calling for the protection of the common law system in Anglophone Cameroon and the practice of the Common Law sub-system in Anglophone courts and not the Civil Law as it was used by French-speaking magistrates”. They equally demanded for the creation of a common law school at the University of Bamenda and Buea [18].
More so, Francophones occupied all the juicy positions in the Supreme Court. Although Francophones had little or no knowledge in English and the Common Law, most of the magistrates and bailiffs in the Anglophone zone were Francophones. Anglophones lawyers were disgruntled of the domination of the Civil Law as if Cameroon was uniquely a Civil Law country. There was equally a problem of translating the Business law for Africa (OHADA) uniform acts, CEMAC code, and others because the Francophones wanted to assimilate the Common Law sub-system.
In Africanews Morning call [19], Barrister Bobga Harmony declared that the government of Cameroon had completely ignored them, which was a violation of the right to self-determination. According to him, “since 1972, they have been a progressive, an inexplicable, illegal and illegitimate erosion of the common law.” He regretted that Francophones had been replacing the Common Law with the French Civil law as if Anglophones “were a conquered people.” The lawyers had complained for years through writing to competent authorities before realizing that if they did not take concrete actions, they would be swallowed up by the dominant Francophone system. So they held a Common Law conference on the May 9, 2015, which was followed by a second conference in Buea where they made a declaration reinforcing their position.
Although they had sent a communiqué to the presidency of the Republic of Cameroon, nobody listened to them. Instead of defending the Common Law lawyers, the Minister of Justice insulted them in the government newspaper: Cameroon Tribune. As a result, they protested and insisted to talk only with the president of the Republic of Cameroon or his properly mandated agent because they had exhausted all negotiation with the executive and the legislature. They had filed a petition to the national assembly and the senate and they were planning to file a petition to the constitutional council for the determination of the question of whether there had been any act of union between West Cameroon and East Cameroon. They planned to proceed to the international jurisdiction like the African Commission for Human and People’s Right, the Human Right Commission if the government did not listen to them. Bobga Harmony said “We are going to seize the international community because these are grave abuses of human rights. The international community cannot fold its arms and allow us to be brutalized in our land,” Barrister Bobga Harmony said in Africanews Morning Call [19].
Teachers and the general public joined the lawyers in the strike. They reportedly opposed what was described as the “imposition of French in schools in Anglophone parts of the country.” According to Catherine Soi reporting for Aljazeera [20], students battled on their own at school because even private school teachers had deserted classroom in support of the public sector teachers and so many classrooms and schools across Ambazonia were empty. They wanted the government to stop sending teachers who spoke only in French or Pidgin English. Even students supported the strike action because after completing school, they were unable to find jobs.
“For over fifty years Anglophone students have not been able to have a headway in Cameroon in most disciplined that bring about development: science and technology because the government has refused to train teachers for our schools,” declared Tassang Wilfred over Aljazeera (2016).
According to University of Buea strike Report [21], a mammoth crowd of students came out protesting in order to attract the authority of the university attention to their plights. A student carried a placard on which it was written: “enough is enough.” They had a variety of complaints: the non-payment of the 50,000frs CFA that the government had promised them, the cancelation of the 10,000frs CFA penalty fees for the late payment of school fees, and the payment of fees before being given a semester result, and as it was the general cry with the secondary and high schools in the Anglophone zone, they also demanded the removal of French-speaking lecturers from the faculty of the university.
They stood in front of the Administrative Block wishing to meet the Vice Chancellor to tell her their problems but instead security forces took her away and a huge number of security forces were sent to dispatch them. As they arrived, the students ran into different directions and the atmosphere became very misty because the security officers had thrown teargas and fired gun shots in the air. The students shouted no violence as they ran away for safety. Although students were beaten and arrested, it did not dampen the spirit of the strike action so the students left and marched into the street.
According to Bamenda protest close to one hundred wounded [22], protesting residents voice other grievances, including – poor roads, no jobs and water. “On November 21, 2016, Mancho Bibixy, the newscaster of a local radio station, stood in an open casket in a crowded roundabout in the Anglophone city of Bamenda. Using a blow horn, Bibixy denounced the slow rate of economic and structural development in the city.”
“When that Chinese them di come, m-e-y they come tell we when they dig road, na we di fix’am back,” he declared his discontent with the bad state of roads that Chinese would only construct but would not repair. He showed his defiant attitude by declaring he was ready to die while protesting against the social and economic marginalization of Anglophone in the hegemonic Francophone state.
“I don tell them, if na teargas I go drink’am.”
“Let them chase me….it won’t mean anything to me,” he declared.
He emerged as a key leader in the Anglophone political movement who were among the first to be arrested and he was later slammed a 15-year prison term (Figure 1).
The White Coffin Revolution. Source: https://www.google.com/search?q=picture+of+white+coffin.
In a video entitled “Bamenda Protest Close to 100 wounded,” [22] it shows how the white coffin was carried about and a mammoth crowd of young men followed it with Bibixy himself leading.
“We can never be defeated by the police,” they declared when the police came to stop them. They rounded-up one of them and chased the others who came to stop their peaceful march. One can clearly hear a voice saying in the video:
“You no take hi gun?” asking whether he has not taken his gun.
“Cameroon must change,”
“That independent na today where i go start o-o,” which means: the independence will start today.
Young men came in their bikes honing while those who were on foot shouted. Protesters were all over the whole streets.
“I say… bamenda di hot yah,” they said in the background.
“We need change in Bamenda,” they said.
“whosai the police them dey where they di try their nonsense, make them come now,” they declared with determination.
Then suddenly trucks of military men arrived shooting in the air and killed a good number and wounded about a hundred.
“Jesus, they are killing us in Bamenda,” they said. Another truck arrived on which it was written “Gendarmerie Nationale” and it sprayed huge amount of water on a hostel: Grand Plaza; certainly where some of the protesters were hiding. The video shows how two persons hurriedly took away a shot person on a bike and some were taken and given private treatment at homes.
In a video entitled: Bamenda Boiling, they Escaped Teargas, on December, 8th 2016 [23], shows some young men shouting loudly and running away as fast as they could from the police who were throwing teargas on them to stop them from manifesting. Some covered their nostrils with handkerchiefs to prevent them from inhaling the toxic gas.
The struggle as well was not only between the Francophone and Anglophone but also between the Anglophone and their elite who enjoyed juice positions in the government and were not ready to resign from their positions. They were enablers: the government used them to crush their own people. They always would preach anti-struggle campaign and would bring other Francophone authorities to fight against their people. Each time they visited the Anglophone zone, there was always a battle between them and their people. The elite wanted to maintain the status quo, while the general population wanted a change.
The video Bamenda Boys against CPDM [24] shows a comic scene where a young man brought a large catapult and took a stone to support the big stick and another one pulled the rope from behind him and then they took the catapult to confront the CPDM barons. According to Zigolo Tchaya 2016 [25] reporting for France 24, when the Prime Minister of Cameroon (an Anglophone) and the Secretary General of the Cameroon People’s Democratic Movement, the party of the government in power, went to Bamenda to hold a pro-government rally with its militants to calm down the striking lawyers and the teachers’ association, who had been striking for 2 months, a group of young men burnt the CPDM party uniform of an elderly person who was going to attend the rally. The angry youth blocked the hotel where the Prime Minister and Secretary where lodging and there was a confrontation between them and the security. According to Gigova [26], it led to four deaths and several wounded and about 50 arrested. The Prime Minister, The CPDM Secretary General, the Governor of the North West region, and the national security adviser were forced to go into hiding.
Cameroon 2018 Human Rights Report [27] states that “although the law provides for freedom of peaceful assembly, the government often restricted this right. The law requires organizers of public meetings, demonstrations, and processions to notify officials in advance and does not require prior government approval of public assemblies, nor does it authorize the government to suppress public assembles that it has not approved in advance. However, officials routinely asserted the law implicitly authorizes the government to grant or deny permission for public assemblies”.
It equally states that, “the government often refused to grant permits for gatherings and used force to suppress assemblies for which it had not issued permits. Authorities typically cited “security concerns” as the basis for deciding to block assemblies. The government also prevented civil society organizations and political parties from holding press conferences. Police and gendarmes forcibly disrupted meetings and demonstrations of citizens, trade unions, and political activists, arrested participants in unapproved protests, and blocked political leaders from attending protests.”
In the Stream: Alzeera 2017 [28], Anne Marie Befoune put it as “The strike action is a reflection of a bigger problem, people have had a lot of pains, frustration and anger in their hearts and they were just looking for the slightest opportunity to express what they feel.” The irony is that each time the security forces brutalized the protesters, they instead united against the common enemy, which was the government security forces.
Government responded by cruelly torturing and exerting inhuman or degrading treatments or punishment on demonstrators. Although the constitution and law prohibit such practices, there were reports that security force members beat, harassed, or otherwise abused citizens, including separatist fighters. Cases have been documented of how security forces severely mistreated suspected separatists and detainees [27].
Below we show videos that demonstrate gross human rights violation of the lawyer, the students and the general public.
The government sent over 5000 troops to thwart the Anglophone crisis. According to Zigolo [25] reporting for France 24 [25], the crisis was considered to be “a strong organized and well-coordinated violence from angry protesters and government did not want to allow that part of the country to be destroyed and the protesters too said they would not stop protesting until the government solved their problem”.
According to StopBlaBlaCam [29], policemen blew the ‘the men in uniform’: lawyers with their batons in Buea. The whole city was also under lockdown, monitored by Special Rapid Response (ESIR), the police and gendarmerie. There was also a strong police presence to face the demonstrators. Incidentally, the policemen were demanding that the lawyers hand over their black robes.
On November 10, 2016, the demonstration of lawyers in Buea in the Southwest region met with heavy-handed police response. Lawyers were reportedly brutalized, their offices ransacked, and their wigs and gowns seized by police. Many were injured and harassed in their cars. Their phones were seized and destroyed, and some were barred from joining the demonstrators. Police reportedly raided hotels in search for lawyers and were harassed by law enforcement officers (Figure 2).
Confrontation between the police and lawyers. Source: Cameroon Online [30].
The video entitled: Uprising 4 Police Brutality on Lawyers [31] clearly shows the commotion that took place in the Muea police station. One sees a police officer running after a young lawyer and then another lawyer is pushed into the police station by yet another policeman. Another lawyer is beaten and pushed out of the police station. The police kicks another who falls down and his watch falls off but the police pulls him up by dragging his coat. A female fat police encourages her colleague to hit the lawyer by clearly articulating the phrase in French “frappe,” “frappez-lui” over and over.
The episodes of police brutality in Cameroon were not limited to lawyers only; it extended to University of Buea students as well as the general public. Many were molested by police and disturbing videos show police officers armed with stick hitting or rolling them in water, invading students’ quarters and beating them.
The videos show appalling images of how French-speaking soldiers, who were alienated from the sufferings of English-speaking citizens, inflicted pains on them. Although they were in the same country, they could not communicate because they spoke different languages.
The video Police and Gendarmes severely torturing University Students in Buea strike [32] certainly was filmed while in the house because of the iron bars of the window. In it, two policemen force a student to lie down very fast: “Couches-toi” the police ordered him to lie down.
“Comment ca,” the young man retaliated by asking why.
“Couche-toi vite,” he ordered again.
“Ne parle pas,” “viens ici,” “Enleve la cle ci,” “viens d’abord ici, regarde la bas,” they continuously ordered him. Then one of them raises his baton and hits him while the other forces him to lie down while they hit him counting the number of strokes in French. The police standing by takes the baton from his colleague and asks the students to roll on the soil while he hits him with all his force. “Tourne, c’est votre pays-ci?” he asked whether it was his country. “Vous savez que vous allez gravez?” he asked while hitting him whether he knew they would go on strike.
The video entitled “2 police and Gendarmes severely torturing University Students in Buea, Buea strike [33] shows with a lot of noise in the background, two policemen harassing university students in their neighborhood. Three university students are laying down, one in a puddle and a female student is brought in and the police man brutally pushed her in the puddle.
“Attend d’abord, je vais te giffler hei,” the policeman said in French threatening to slap the girl and then the girl’s leg is pulled and is forcefully pulled in the puddle, rubbing her head in it.
“They go kill man,” they camera man exclaimed that they would kill them.
The Southern Cameroon updates: Police Brutality at UB 28/11/2016 [34] certainly taken from a story building shows how a group of police and gendarmes in the street of Molyko molested a young man. While one of the policemen was pulling him ahead, another one came from behind and kicked him and he fell down. It is clearly seen how one of the security officers had wounded a female student’s head, one also sees a student whose t-shirt had been torn and blood dripping from his head.
The video: Université de Buéa - les forces de l’ordre entrent dans les residences et tortuent des etudiants [35] starts with the camera woman inviting fellow students to run for safety. “Yuna enter o-o-o-h,” she invited other students. Then students are seen running very fast into their residence for safety as scores of security men followed them behind with batons. They caught some married women and hit them severely. “They go kill we that married woman them, I swear,” the camera women lamented. A woman is drawn from her house and mercilessly hit by the security officers. “Pour les hommes faire les descendre,” an order is given in French to bring out all men. “Faire descendre tout les hommes,” the order is repeated for emphasis. A boy is removed from his house and the French-speaking security officers hit his head with their batons.
“Amenez-le, ca va,” an order is given and the boy is held from his belt.
The Centre for Human Rights and Democracy in Africa [36] reported that at least 14 student hostels were attacked that day. More than 140 rooms were vandalized, their occupants tortured on the Buea (Molyko) main boulevard, and some students were asked to sing that “an Anglophone will never rule the country.” Even though most students were finally released, several of them spent 3 days in detention facilities in overcrowded cell conditions, with little or no communication with their families.
The video Bamenda in turmoil today December, 2006, part 1 [37] shows a group of predominantly young men lamenting because a police had shot one of the protesters who wore a t-shirt with white and red lines on it, stained by blood and mud. He lay helplessly in the hands of his comrades.
“Oh my God, wait, wait. Bring he s-o, hold i hand,” they held him and he dangled in their hands while those around him lamented.
The video This is Bamenda [38] shows a group of young men carrying peace plants and marching very fast in a street in Bamenda. They were carrying a dead young man to the main street in Bamenda called the Commercial Avenue. The commentator said “Bamenda is turning into something else,” which means that many people are dying in Bamenda, and then he calls on “BBC, CNN and Alzeera, you guys need to support us, people are dying,” he said. The spectators and the participants shouted and lamented.
“Y-e-e-u-h Bamenda, Bamenda, Bamenda, Bamenda,” he shouted several times.
“w-e–e–e-h massa,” he shouted several times again. Then the dead man is shown with a blue band that fastened him to the stick he was tied. He is being carried away by other young men marching very fast and singing: “Amba, Amba, Ambazonia.” It means they identify themselves more with Ambazonia than Cameroon.
The various videos incriminated Cameroon security forces and therefore as a result as [27] shows Cameroon experienced its first Internet shutdown in January 2017 for 93 days. It came after Anglophone teachers, lawyers, and students went on strike over alleged social bias in favor of Francophones. Education, financial, and health-care institutions as well as businesses that relied on Internet access were stunted. International bodies applied pressure on the government to restore Internet access. Despite Internet access being restored in April 2017, there were continuing reports of network instability. In October 2017, the government effected a second Internet blockade, targeting social media and apps such as Whatsapp and Facebook where such videos as those described above were sent. It continuously affected the country economically, and many citizens were forced to travel back and forth to regions with Internet access for business or information.
Two weeks into the protests, more than 100 protesters were arrested, and six were reported dead [39]. Throughout September, separatists carried out two bombings: one targeting security forces in Bamenda Quartz Africa [40], and while the first bombing failed, the second injured three policemen Reuter [41]. On September, 22, Cameroonian soldiers opened fire on protesters, killing at least five and injuring many more [40]. On November 30, 2017, the president of Cameroon declared war on the Anglophone separatists Sun Newspaper [42].
“I have learned with emotion the assassination of four Cameroonians military and two policemen in the South of our country --- things must henceforth be clear. Cameroon is victim of repetitive attacks claiming a secessionist movement. Facing these aggression acts, I would reassure Cameroonians that everything has been put in place to take out of the dark these criminals so that peace and security reigns all over the territory.” This marked the start of a very violent confrontation between government forces and armed separatists.
Non-state actors, including local armed groups, also bear much responsibility for the violence. Separatist militias are battling government forces as well as pro-government “self-defense” forces that consist of what separatists term criminal gangs who are terrorizing local inhabitants and wreaking havoc. The military also conducts a deliberate violent campaign against civilian population. Lawyer Right Watch Canada [43], “There is evidence that much of the violence is intentional and planned, including retaliation attacks on villages by government security forces, often followed by indiscriminate shooting into crowds of civilians, invasion of private homes and the murder of their inhabitants, and the rounding up and shooting of villagers.”
According to the International Crisis Group, at least 1850 people have been killed since 2017; the ICG reports that at least 235 soldiers and police officers and 650 civilians, and close to 1000 separatists have lost their lives; and Anglophone federalists estimate 3000–5000 dead, and separatists estimate 5000–10,000 dead.
The Centre for Human Rights and Democracy in Africa [44] reports that in early January 2017, the Cameroon Anglophone Civil Society Consortium (Consortium or CACSC) agreed to meet with the government about the release of protesters arrested during a 2016 demonstration in Bamenda. The Consortium accused the government for shooting four unarmed youth and proceeded to declare “Ghost Towns” on January 16 and 17. The reports equally state that, “in response, the government cut the Internet and banned the activities of two groups: the Southern Cameroon National Council (SCNC) and the Consortium on January 17, 2017. The same day, two prominent Anglophone civil society activists who headed the Consortium: Dr Felix Agbor NKongho and Dr Fontem Neba were arrested”.
On January 9, 2017, armed soldiers forcibly entered the home of Mr Mancho Bibixy, a journalist and Newscaster of “Abakwa” (a local radio program reporting on the rights of the Anglophone minority), and arrested him, along with six other activists. He was taken to a vehicle with neither shoes nor identification papers and was arbitrarily detained for 18 months and his hearings were postponed for more than 14 times.
On May 25, 2018, Bibixy and his co-accused were sentenced to between 10 and 15 years of prison each by a military court, for acts of terrorism, secession, hostilities against the state, propagation of false information, revolution, insurrection, contempt of public bodies and public servants, resistance, depredation by band, and non-possession of national identity card. He was being held in an overcrowded cell at the Kondengui Central Prison, a maximum-security prison in Yaoundé.
Between September 22 and October 17, 2017, 500 people were arrested, with witnesses describing the detainees as being packed into jails in the South West region. In December 2017, a group of about 70 heavily armed Cameroonian soldiers and BIR sealed the village of Dadi and arrested 23 people returning from their farm or were in front of their homes.
On January 5, 2018, 47 separatist activists, including Sisiku Ayuk Tabe of the proclaimed Interim Government of Ambazonia, were arrested and detained by Nigeria authorities in Abuja. The detainees were repatriated afterwards and imprisoned in Yaoundé incommunicado for 6 months awaiting trials. They were not given access to their lawyers nor charged with any offense.
Mass arrests and detentions have caused harsh and often life-threatening prison conditions in Cameroon, including gross overcrowding, lack of access to water and medical care, and deplorable hygiene and sanitation. Prisoners are transferred out of the region to other more secure areas.
Several hundred thousand persons abandoned their homes in some localities of the Northwest and Southwest Regions because of the socio-political unrest. Estimate of IDPs varied depending on the source, with the government estimating 74,994 IDPs as of June, while the United Nations estimated 350,000 IDPs from the Northwest and Southwest as of September.
On December 2017, the Senior Divisional Officer for Manyu: Oum II Joseph asked the population of Manyu residents in Akwanga, Eyumojock, and Mamfe sub-division to relocate or they would be considered accomplices or perpetrators of ongoing criminal occurrences registered on security and defense forces [45].
By the end of December 2018, the crisis had forced mass displacement of the population in the North West and South West regions, with estimates of between 450,000 and 550,000 displaced persons. This represents more than 10% of the region’s population. Cameroon now has the sixth largest displaced population in the world. Many are fleeing violence as a result of raids on villages and surrendering areas. They take refuge in the forests where they lack hygiene, health services, sanitation, shelter and food. The United Nations Office for the Coordination of Humanitarian assistance estimates that approximately 32,000 Cameroonians are registered refugees in Nigeria. More than 200 villages have been partly or completely destroyed, forcing hundreds of thousands of people to flee. The rate of attacks has increased steadily, usually causing significant damage. An additionally 30,000 to 35,000 people have sought asylum in neighboring countries.
Separatist activists who seek an independent state for the country’s English-speaking regions began to set fire on schools and attack teachers and students to enforce a boycott they had declared on local schools. In June 2018, UNICEF reported that at least 58 schools had been damaged since the beginning of the crisis in 2016. Human Rights Watch documented 19 threats or attacks on schools, and 10 threats or attacks on education personnel (Figure 3).
Government soldiers supervising the burning of a school and a burnt school [46].
Most children in the two regions have been deprived of the right to an education, with 30, 000–40,000 children affected. As of June 2018, armed separatists had reportedly attacked 42 schools, at least 36 of which were burnt down; the Cameroonian’s figure indicated that they had burnt at least 120 schools. Rural areas are especially affected.
Anglophone villages suspected of harboring separatists or arms have been burned and pillaged in both the South West and North West regions. Homes have been burned to ashes, sometimes with their inhabitants. About 206 settlements have been raided and partially destroyed by state defense forces during attempts to crack down on armed separatists. Several villages in Mbonge and Konye subdivision have been completely emptied of their population. Civilian witnesses say that army attacks are routinely followed by the ransacking of houses and shops, the destruction of food stocks, and the rounding up and mistreatment or killing of civilians, often as reprisals for their killing of a member of the defense and security forces (Figure 4).
Genocide in Ambazonia, burning of villages and IDPs [45].
One of the key ways social movements engage in cultural resistance is by means of the production and dissemination of multiple forms of media in order to mobilize support, to reach out for supports beyond those already in agreement with movement claims, and to increase the legitimacy of their claims and demands. Social movements operate at a considerable disadvantage when trying to influence news portrayals of issues than do their better-funded opposing groups and organization.
Anglophones or Ambazonians who are defending themselves from the Cameroon security forces that kill them are presented in the state television and other media as “terrorists” and never as those fighting for a just course, whereas as seen above, they did not start the war; it was declared on them. The main stream media equally promoted hate speech and incitement to violence, which radicalized separatist groups the more. Government officials refer to protesters in dehumanizing or incendiary terms, such as “dogs” and “terrorists” in the main stream media. When the security agents who terrorize the population are presented in mainstream media, they are considered as valiant and patriotic agents of the republic who protect the population. Did they really protect the population when they tortured them, arbitrarily arrested them, and burned their houses as seen above?
Therefore, media serve to propagandize and serve the interests of the powerful that control and finance them. The propaganda model shows that media function to represent the agendas of the dominant social, economic and political groups that exercise power nationally and globally. Therefore, social movements face difficulties in their attempts to transmit their claims and to traverse the gap between their intended messages and their target audiences.
Activists in the Ambazonian crisis created a strategy that Mattoni [47] considered as alternatives that are the creation of their own independent media or public forums of communication in order to communicate for a lack of interest or bias by established media. Alternatively, in the Ambazonian crisis, many videos were produced that facilitated the mobilization and production of a counter-narrative to the ‘official story,’ which indicates that there is no Anglophone problem in Cameroon and the professionalism of the security forces. The Internet makes the process of sharing easier and faster and with a potentially larger audience than ever before. These messages in the videos from the alternative media environment have made their ways into mainstream mass media like the various reports carried by BBC, France 24, TV5 Monde, etc.
The Ambazonia crisis was triggered by the Southern Cameroonians’ attempt to break the dominant Francophone cultural hegemony. They came into union with them from a weaker position with a population numerically smaller. As a result, La République du Cameroon has been making efforts not just to dominate them but to absorb them into the broader Francophone cultural system. They silently destroyed the dignity and statehood of Anglophones-not by the French-speaking community at large, but by the government that was led and dominated by Francophones.
Toward the end of 2016, the two Anglophone regions were rocked by demonstrations and strikes, initially led by lawyers, teachers, and students and eventually involving a wider section of the population. They protested against what they viewed as the growing marginalization of the Anglophone linguistic, cultural, educational traditions and systems in various sectors such as the failure to use the Common Law in courts and Standard English in classrooms, as well as the improvement of their representation in politics.
Many videos were produced showing their repressive response of the government, which were opposed to the official narratives produced by the main stream media. We collected 30 of them because they provide information that cannot be provided by other types of data. They are used as ‘proofs of facts.’ The videos show appalling images not just of how French-speaking soldiers tortured Anglophones but also their inability to communicate with them adequately although they share the same country.
The government response to the demonstration led to the violation of the following rights: the right to life, liberty, and security of persons; the right to be free from torture or cruel, degrading and unusual treatment; the right to be free from arbitrary arrest and detention; the right to association and peaceful assembly; the right to equality before and equal protection of the law; the right to take part in the conduct of public affairs; the right to have criminal charges and rights determined by a competent, impartial and independent tribunal (and in the case of civilians, a civilian court); the right to a fair trial, representation by a lawyer of choice, and (where the defendant does not have means to pay for legal representation) legal aid; the right to prompt, detailed notice of charges in a language understood by the defendant and adequate time and facilities to prepare a defense against them and communicate with counsel; the right to an interpreter where required; the right to appeal; the right not to be persecuted for any act or omission that was not a crime when committed; and the right to self-determination.
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