Hidden leaders: vacuums of leadership

What happens when a head of state goes AWOL?

The aptly named Goodluck Jonathan took over as acting president of Nigeria this week, filling the vacuum left by the long absence of President Umaru Yar'Adua. It's not as unusual as you might think: other heads of state have been ill, have died, or have simply not been there much of the time.

But let's begin with the case of Nigeria today:

1. President Umaru Yar'Adua (Nigeria)

Yar'Adua has not been seen in public since he went to Saudi Arabia for medical treatment on 23 November 2009. The Nigerian constitution requires the president to inform parliament formally of his absence before power can be transferred -- but he didn't do this before he flew out of Abuja, leaving his country leaderless.

Conspiracy theories abounded, variously that he was dead, brain-dead, or no longer in hospital. The past three months have been fraught with legal challenges, cabinet splits, mass protests, and tensions resurfacing in the Niger Delta. Eventually, the National Assembly voted in favour of Vice-President Goodluck Jonathan stepping in. It remains to be seen how successful he will be in ending the turmoil.

2. Kim Jong-il (North Korea)

The whereabouts of the elusive North Korean leader have been the subject of heavy speculation since 2008. In August that year, Toshimitsu Shigemura, a Japanese academic and expert on North Korea, claimed that the Great Leader had died in late 2003 and been replaced at public appearances by stand-ins, previously employed to protect him from assassination attempts.

On a slightly less far-fetched note, questions about Kim's health were raised when he failed to appear at a military parade for the 60th anniversary of the founding of North Korea, on 9 September 2008. US intelligence agencies believed that he could be "gravely ill" after suffering a major stroke, although Pyongyang downplayed this.

Various reports have suggested that he has since suffered a second stroke, or that he has pancreatic cancer. The Times has questioned the veracity of at least one photograph released to prove that he is still alive. However, Kim met with Bill Clinton in August last year to negotiate the release of two Americans. No doubt conspiracy theorists would say that Clinton met with one of his impersonators.

3. Fidel Castro (Cuba)

The long-time Cuban leader handed over power to his brother, Raúl, in July 2006, and resigned from the presidency in 2008. But this followed years of speculation about Castro's health, beginning in 1998 with the rumour -- since discredited -- that he has a terrible brain disease.

The belief that his health was failing gathered force in 2004, when the mayor of Bogotá said that he "seemed very sick to me", and the following year when the CIA said he had Parkinson's disease (which he denied).

Since then, it has been widely accepted that he is seriously sick, with some speculating that he has a terminal illness. On reports of his recovery, George W Bush said: "One day the good Lord will take Fidel Castro away." Although he has officially retired from public affairs, Cubans still worry that he might be dead.

4. Lansana Conté (Guinea)

Conté became Guinea's leader by staging a coup d'état in 1984. On falling ill in 2006, he was reluctant to relinquish power, creating a leadership vacuum that led to an outbreak of violence. In April 2006, he was flown to Morocco for medical treatment, amid riots in Guinea over the price of rice and fuel. He returned, but was physically and mentally incapacitated, leaving the door open for his wife, Henriette, to flout the rule of law.

Despite his illness, Conté insisted he would stay in office until the end of his term in 2010. A general strike brought the country to a halt for two weeks in 2007, hundreds of thousands of workers taking to the streets to protest against his leadership.

Many died in violent clashes with security forces. The strike came to an end when Conté agreed to appoint a new prime minister, Lansana Kouyaté, as acting head of government. Yet he declared on television that year: "I'm the boss, others are my subordinates." He then undermined Kouyaté and soon replaced him with another proxy.

Conté died of natural causes in December 2008. Within hours of the new prime minister announcing his death, junior army officers staged a coup, bringing Captain Moussa Dadis Camara to power. His junta failed to bring stability to Guinea. Last September, a contingent of presidential guardsmen massacred more than 150 opposition supporters at a rally in the capital, Conakry. Then, in December, an aide to Camara shot him in the head; he was flown out to Morocco for medical treatment.

On 13 January, after an absence of six weeks, Camara left Morocco for Burkina Faso. He is yet to return from there to Guinea, but in his absence an official investigation declared him free of all responsibility for the September massacre.

5. Saparmurat Niyazov (Turkmenistan)

And finally, a potential crisis of leadership that ended well. You might not have heard of Saparmurat Niyazov, the Turkmen dictator, who was compared to Stalin and -- yes -- Kim Jong-il for his draconian rule.

Criticised internationally as one of the world's most repressive dictators, he encouraged a bizarre cult of personality, renaming months of the year after members of his family, and replacing the word for bread with his mother's name. He also banned the opera and the circus for not being Turkmen enough.

When he died in December 2006, the oil- and gas-rich central Asian nation was left in turmoil as essentially he was the entire state. Happily, fears that the vacuum created by his death would lead to a power struggle between different regions, or even civil war, were not realised. Vice-President Gurbanguly Berdimuhamedow took over, repealing some of Niyazov's stranger policies, and tentatively opened up relations with the west.

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Samira Shackle is a freelance journalist, who tweets @samirashackle. She was formerly a staff writer for the New Statesman.

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A swimming pool and a bleeding toe put my medical competency in doubt

Doctors are used to contending with Google. Sometimes the search engine wins. 

The brutal heatwave affecting southern Europe this summer has become known among locals as “Lucifer”. Having just returned from Italy, I fully understand the nickname. An early excursion caused the beginnings of sunstroke, so we abandoned plans to explore the cultural heritage of the Amalfi region and strayed no further than five metres from the hotel pool for the rest of the week.

The children were delighted, particularly my 12-year-old stepdaughter, Gracie, who proceeded to spend hours at a time playing in the water. Towelling herself after one long session, she noticed something odd.

“What’s happened there?” she asked, holding her foot aloft in front of my face.

I inspected the proffered appendage: on the underside of her big toe was an oblong area of glistening red flesh that looked like a chunk of raw steak.

“Did you injure it?”

She shook her head. “It doesn’t hurt at all.”

I shrugged and said she must have grazed it. She wasn’t convinced, pointing out that she would remember if she had done that. She has great faith in plasters, though, and once it was dressed she forgot all about it. I dismissed it, too, assuming it was one of those things.

By the end of the next day, the pulp on the underside of all of her toes looked the same. As the doctor in the family, I felt under some pressure to come up with an explanation. I made up something about burns from the hot paving slabs around the pool. Gracie didn’t say as much, but her look suggested a dawning scepticism over my claims to hold a medical degree.

The next day, Gracie and her new-found holiday playmate, Eve, abruptly terminated a marathon piggy-in-the-middle session in the pool with Eve’s dad. “Our feet are bleeding,” they announced, somewhat incredulously. Sure enough, bright-red blood was flowing, apparently painlessly, from the bottoms of their big toes.

Doctors are used to contending with Google. Often, what patients discover on the internet causes them undue alarm, and our role is to provide context and reassurance. But not infrequently, people come across information that outstrips our knowledge. On my return from our room with fresh supplies of plasters, my wife looked up from her sun lounger with an air of quiet amusement.

“It’s called ‘pool toe’,” she said, handing me her iPhone. The page she had tracked down described the girls’ situation exactly: friction burns, most commonly seen in children, caused by repetitive hopping about on the abrasive floors of swimming pools. Doctors practising in hot countries must see it all the time. I doubt it presents often to British GPs.

I remained puzzled about the lack of pain. The injuries looked bad, but neither Gracie nor Eve was particularly bothered. Here the internet drew a blank, but I suspect it has to do with the “pruning” of our skin that we’re all familiar with after a soak in the bath. This only occurs over the pulps of our fingers and toes. It was once thought to be caused by water diffusing into skin cells, making them swell, but the truth is far more fascinating.

The wrinkling is an active process, triggered by immersion, in which the blood supply to the pulp regions is switched off, causing the skin there to shrink and pucker. This creates the biological equivalent of tyre treads on our fingers and toes and markedly improves our grip – of great evolutionary advantage when grasping slippery fish in a river, or if trying to maintain balance on slick wet rocks.

The flip side of this is much greater friction, leading to abrasion of the skin through repeated micro-trauma. And the lack of blood flow causes nerves to shut down, depriving us of the pain that would otherwise alert us to the ongoing tissue damage. An adaptation that helped our ancestors hunt in rivers proves considerably less use on a modern summer holiday.

I may not have seen much of the local heritage, but the trip to Italy taught me something new all the same. 

This article first appeared in the 17 August 2017 issue of the New Statesman, Trump goes nuclear