Part 2: I’ve closely followed COVID-19 coverage for more than 1 year. Here are my key takeaways.
It was a busy Clinic day in
the Outpatient unit. All adult patients were required to wear a face mask
before entering the Clinic. Yet, some patients came in without masks. Usually,
we asked those patients without a mask to get one before they could be attended
to. On this day, an elderly patient walked into the consulting room without a
mask. Instead of asking him to go get a mask, I gave him a spare mask that has
not been used. The patient thanked me and we began the consultation. I was
putting down some notes in the patient folder when he coughed. I looked up and
saw that this elderly patient had lowered the mask to his chin and was coughing
into his bare hands. What! ‘What is the essence of having a mask on, if you are
going to remove it to cough’, I wondered. I was so upset that I kept quiet for
some seconds to regain my composure. He was an elderly patient, what can I say
to him! Each time I remember that incident, I do pause to think. The patient should
not bear all the blame for his action. I gave him a mask to wear without
explaining to him why he should wear it and what to do while wearing it. I
didn’t educate him about the use of the mask; I just assumed he knew and that
he would comply. It’s not enough to tell people to do certain things or abide
by certain rules, there is a need to educate them about what you want them to
do, and to guide them while they are doing it.
In continuation of my series
discussing the things I observed while closely following the COVID-19 coverage
over a year, I’ll be discussing yet more lessons I have learnt and I’ll be
offering my perspective on the way forward. In Part 1 of this series (link: https://dreugeneoji.blogspot.com/2021/04/ive-closely-followed-covid-19-coverage.html), I wrote about
the need for key Public Health institutions to work hard to regain the faith
and trust people have in them. I also talked about the need for good
communication. ‘Good science needs good PR’, I wrote. Lastly, I emphasized the
need to actively and aggressively combat false information about COVID-19 on
social and traditional media. Having covered 3 key takeaways, I’ll continue
with another point, that is the 4th point:
4. The need for constructive engagement before
applying strict enforcement.
COVID-19 took many by
surprise. Governments, governmental agencies, global and local authorities were
surprised by the scale and durability of the COVID-19 disease. Even countries
that had high ratings in the pandemic preparedness scale like the US were found
wanting when COVID-19 struck. So, there was a rush to do something to prevent
the spread. Some measures were so hastily put in place that people had little
or no time to process them before they were strictly enforced. China, where the
first cases of COVID-19 were discovered, took pretty drastic measures. A strict
lockdown was put in place in Wuhan, and Hubei Province. You couldn’t leave the
house without the permission of the authorities, and if you were found to have a fever, you were taken, sometimes forcefully to an isolation area. The
authoritarian nature of the Chinese Government ensured that these strict
measures could happen with little or no resistance from the populace. When the
disease hit Italy, a European country, the Italian Government tried some form
of lockdown that was nowhere near what China did. European countries and other
Western countries pride themselves in freedom of movement and of thought. There
was much more resistance to the lockdown measures in Europe, US, and other
places. However, countries like New Zealand had much success in maintaining a
lockdown while maintaining popular public support for that measure. How did the
then 39-year-old Jacinta Ardern, the Prime Minister of New Zealand, manage to
ensure a lockdown in New Zealand and yet maintained popular support?
According to an article in The
Atlantic Magazine (link: https://www.theatlantic.com/politics/archive/2020/04/jacinda-ardern-new-zealand-leadership-coronavirus/610237/ ), the relatively
young female Prime Minister of New Zealand was a “communicator”. She showed
“empathy” and was able to clearly communicate with her people in a
down-to-earth manner about the then impending lockdown. The people felt that their
leader cared about the difficulties that a lockdown would bring and thus trusted
her to guide them through it. As I said in Part 1, communication is key in any
crisis, including a global pandemic. And communication was clearly lacking in
some countries and regions where lockdowns were instituted.
In Nigeria, some States
initiated lockdown within a day or 2 of receiving reports of a confirmed
COVID-19 case in their States. This fire brigade approach was problematic to
say the least. Those subregional Governments did not take the time to engage
with the people, to discuss and level with them about the need for such
lockdowns. The average Nigerian doesn’t have much faith in the Government
because of failed promises and unmet expectations. There were false information
making the rounds that the political elites simply want to enrich their pockets
with the COVID-19 crisis. So, people don’t necessarily listen to and follow
what the Government says. Nigerians listen more to their religious, traditional
and community leaders, and they are more inclined to follow what their Imam, Pastor
or Traditional ruler tells them to do. What the Government needed to do was to
engage with these leaders, and get their support in the COVID-19 fight. If the
Government were able to persuade many of these leaders, they in turn would
talk to their followers on the truly deadly nature of the COVID-19 disease. As
I said in Part 1, many Nigerians took salty water in the name of protecting
themselves from Ebola. That was not an instruction from the Government. It was
messages from their traditional and religious leaders that lead them to do
that. The COVID-19 fight in Nigeria would have gone more smoothly if the
Government and governmental agencies were able to actively engage and gain the
support of many opinion leaders and the people at large. But that was not the
case!
As I have mentioned earlier, in
some States in Nigeria, lockdown was hurriedly put in place. Gatherings,
meetings, sport events and public events were closed. The security personnel
were out in full force to maintain the lockdown. Security agents entered places
of worship, and events centres to chase people out. The people were intimidated
into compliance. Whatever success that approach achieved in the COVID-19 fight
was matched with anger, animosity, distrust, and apathy from the public. Aside
from the communication failures, adequate preparations were not made to help
many who rely on daily income to take care of their families. Faced with
unemployment, little or no income, hunger, some took to the streets to protest
the lockdown, others took to illegal and criminal activities to make ends meet.
The lockdown might have contributed to better outcomes with COVID-19 in Nigeria,
but the manner of execution and the failure to robustly engage and prepare the
people for such measures could have driven a bigger wedge between the people
and the Government.
The elderly patient I
mentioned at the outset could have benefited from some health education and
interaction about the use of the facemask before been made to wear one. It is
difficult for people to follow rules and policies when they’ve not been enlightened
about such rules and policies. What efforts were made to try and bring opinion
leaders, religious and traditional rulers on board with the lockdown measures
before strict enforcement was enacted? In any crisis, health inclusive, it
helps to gain the trust and respect of people. It helps to listen to people,
hear their concerns, and then bring yourself down to meet them at their level.
Talk openly, truthfully and frankly about the challenges of the crisis and why
certain measures, albeit difficult, needed to be taken to curb the crisis. It
took some time for COVID-19 to get to Nigeria and it took some time for all
States to record confirmed cases. That time could have been spent talking to
the people, preparing them physically and mentally on what is to come. And that
would have softened the blows of the hardships that came with restriction of
movement and the downturn of economic activities. The rush to enforce first and
explain later is like putting the cart before the horse.
5. COVID-19: Lessons learnt
and then forgotten?
When faced with challenges and
difficulties, we often engage in sober thoughts and self-reflection. We tell
ourselves that we surely must learn from this and do better next time.
Sometimes, however, when the challenge or difficulty comes to an end, so too
the lessons learnt. We forget! In the heat of the COVID-19 crisis in Nigeria,
certain things quickly became obvious. The inadequacies of the health care
system in Nigeria became more pronounced. The rich and the connected elites who
fly out of the country to seek medical care abroad suddenly found themselves
with no choice but to use the health care system that Nigeria can provide. The
Chairman of the then PTF (Presidential Task Force) on COVID-19 (now a PSC,
Presidential Steering Committee) in Nigeria, Boss Mustapha, said something to
the effect that he never knew how bad the health care system in Nigeria was.
Even though he was criticized for that statement, Boss Mustapha was simply
stating the obvious. The shortcomings of our health care infrastructures and
capacity become ever more glaring. The pandemic also revealed some other issues
that needed to be addressed. At the height of the COVID-19 crisis in Nigeria, it
seemed for a moment that we (in Nigeria) have learnt our lessons and that this
time around things would change for the better. But, not long after, as the
cases of new COVID-19 infections started to drop, as life began to return to
some normality, we seem to have quickly forgotten the lessons we had learnt
from COVID-19. Here are some examples:
Investing in our health care
system. If you have worked in the health care sector in Nigeria you will realise
that there are a lot of challenges and shortcomings. One of the problems is the
inadequacy of skilled and well-trained man power. The bulk of well-trained
health personnel are concentrated in tertiary health institutions, some secondary
health care facilities, and few private hospitals mainly in urban areas, while
many primary and secondary health care institutions are short on such
personnel. While the Federal Government and State Governments claim to be
training health workers in various academic institutions both in Nigeria and
abroad, oftentimes these “trained” personnel are not deployed to cover gaps in
the number of required health care workers. There is the huge issue of “brain
drain” where doctors trained in Nigeria travel outside the country in search of
greener pastures. COVID-19 unravelled the dearth of critical equipment like
mechanical ventilators. There is the story of a tertiary health institution in
Nigeria with just 3 mechanical ventilators, and one had to be taken away when a
VIP (Very Important Personality) had COVID-19. Some health institutions had ventilators that
were not functional. And there was a shortage of well-trained staff to man
these ventilators when they are functional. Granted, countries like Italy and
US also had shortage of ventilators and trained staff to man them at the peak of
their COVID-19 crisis. So, if countries that are well-developed with state-of-the-art
health care facilities were found wanting due to the surge of COVID-19 patients
in those countries, imagine the situation in countries that ab initio had poor
health care systems. Several medical associations like the NMA (Nigeria Medical
Association), NARD (National Association of Resident Doctors), and others, have
long held that poor investment in health care is one of the key reasons for the
shambolic health system we have in Nigeria. Hence, with COVID-19 hitting
Nigeria, and with no where to run to (as the borders were closed), many
Nigerian leaders and elites were making passionate calls for a more robust investment
in health care. At the time, it actually seems that the tide has turned.
However, as the number of cases of COVID-19 infections started dropping, and
the borders were once more open for overseas medical tourism, and the attention
of the Government and the public has shifted markedly to the security
challenges and economic hardships plaquing Nigeria, one could only wonder if we
have forgotten the calls for more investment in health care.
Looking inward to create
innovative solutions to our health challenges. Prior to the COVID-19
pandemic, China was the leading world producer of essential health items like
masks, gloves, etc. But when COVID-19 started in China, the Chinese authorities
imposed strict lockdown in parts of China most affected by COVID-19. Many
countries did impose travel ban on travellers from China. The effect was that
the supply chain for many health care products dried up. Nigeria, been an
import economy, rely heavily on goods and commodities imported from China. So,
Nigeria, and many other countries dependent on China, suffered shortages of
PPEs (personal protective equipment, like surgical masks) and other essential
health items. Faced with this reality, many countries were looking for
alternative sources for these materials. Many, including Nigeria, looked
inward. Individuals, organized bodies, institutions, etc., looked for ways of
making some of these essential items locally. Armed with the WHO recipe for
making hand sanitizers, many started making hand sanitizers in small- and
large-scale settings. Some invented equipment for handwashing in a public place.
Various universities, like UDUS (Usmanu Danfodiyo University Sokoto), and UNIBEN
(University of Benin) came up with locally made mechanical ventilators. NASENI
(National Agency for Science & Engineering Infrastructure) came up with different
inventions, including a locally made ventilator. A fabrication engineer, Jerry
Mallo and his company, Bennie Agro Ltd (in Jos, Plateau State) built a handwashing
machine and a respiratory device. There was a huge media buzz on these
indigenous innovations at the time. Now, many months have passed and it seems
we have forgotten. China has started scaling up production of goods to export
to other countries. Nigeria got donations of PPEs, ventilators and other
essential items, from wealthy nations and philanthropic organizations, and we
have returned to the import-driven mentality that we had pre-COVID.
The Almajiri lesson. The issue of the
Almajiri system have been a thorny issue in our polity, especially in the North.
Prior to COVID-19, some, like Mallam Nasir El-Rufai, the Governor of Kaduna
State, had called for the end of the system, while others sought for a reform
of the system. A UNICEF article (link: https://www.unicef.org/nigeria/stories/children-adjust-life-outside-nigerias-almajiri-system ) described “the
Almajiri system” as that where “parents send their children, mostly boys aged 4
-12, to distant locations to acquire Qur’anic education” under the guidance of
a teacher. These children often “beg in the streets to fund their education”. When
COVID-19 was spreading in the Northern part of Nigeria, the proponents of
changing the Almajiri system saw an opportunity. The Governors of the Northern part of Nigeria
met and decided that all States should repatriate Almajiri children back to
their home States. Several States took
steps to reintegrate these children with their parents and loved ones. When
Kano State repatriated children who hail from Kaduna State back to their home
State, many of them tested positive to COVID-19. Those revelations brought more
attention to the Almajiri issue. At that time, one could hardly find an
Almajiri child on the streets. Things were really changing, or so I thought. In
recent times, however, the streets are packed with children begging for arms.
What happened to the promise that things would be different this time? Have we
forgotten this lesson of COVID-19 to take care of the children and help them
leave the streets?
6. Investing in primary health
care and public health, not just specialized hospital care.
The borders were closed, many
countries placed bans on travel from other countries at the height of the first
wave of COVID-19 infections. Influential Nigerians who were sick with COVID-19
could not travel out of the country to seek medical care as was the case
pre-COVID. Stuck in Nigeria, some of these individuals were seen or taken to
Lagos. Lagos has a private hospital, First Cardiology Consultants Hospital,
where severely ill COVID-19 patients could be offered a procedure called ECMO (Extracorporeal Membrane Oxygenation). The Mayo Clinic
describes it this way:
“In ECMO, blood is pumped outside of your body to a
heart-lung machine that removes carbon dioxide and sends oxygen-filled blood
back to tissues in the body. Blood flows from the right side of the heart to
the membrane oxygenator in the heart-lung machine, and then is rewarmed and
sent back to the body. This
method allows the blood to "bypass" the heart and lungs, allowing
these organs to rest and heal. ECMO is
used in critical care situations, when your heart and lungs need help so that
you can heal. It may be used in care for COVID-19, ARDS and
other infections.” (Link: https://www.mayoclinic.org/tests-procedures/ecmo/about/pac-20484615 )
ECMO is the last resort when a
patient is not doing well on other means of ventilatory support like mechanical
ventilation. It seems (I stand to be corrected) that only the First Consultants
Hospital mentioned above offer ECMO to patients in Nigeria. That was the reason
why notable Nigerians like Mallam Abba Kyari (the late Chief of Staff to the Nigerian
President), and former Oyo State Governor, Abiola Ajimobi, reportedly died at
that hospital. Those developments have led some to suggest that Nigeria should
build world class hospitals that can offer highly specialised services (like
ECMO) to Nigerians. Some say that would discourage Nigerians from going abroad,
and that would help in the event that international travels are halted again. I
understand that argument, and it would help to have such top-class hospitals in
Nigeria. But, consider these questions: how many Nigerians can afford to go to
such top-class hospitals? How many patients can such hospitals accommodate when
there is a surge of sick patients? Traveling abroad to receive medical
treatments will not stop even if you build such hospitals in Nigeria. In large
part, traveling out for medical tourism has to do with the psyche of Nigerians
who travel out. Yes, there are situations that warrant such medical trips
abroad; for example, Nigerians who need organ transplantation. There are
hospitals in Nigeria where things like kidney transplantation are carried out,
but those hospitals are few, and the fewer the cases of transplantations done
in such centres, the less the confidence people have in the experience &
expertise of those doing the procedures. That said, the psyche or mentality of
Nigerians in general is that better health care is offered abroad, anywhere
abroad, even though we know that that is not always the case. It’s difficult to
change that psyche with just building more hospitals. More so, focusing on
building better new hospitals in Nigeria will surely take away funds to upgrade
and maintain the hospitals we already have. The focus can’t just be on better,
bigger hospitals, the health care system has to be looked at wholistically and
ways to revamp it need to be pursued.
Dr Fauci mentioned in an
interview that one of the problems the US has in tackling COVID-19 is reduced
interest and investment in Public Health in the US. He said that the advances
in science and modern medicine have made the traditional public health
structures to take a back seat. Going forward, Dr Fauci said that more
attention should be paid to public health. Take contact tracers. When a case of
COVID-19 is diagnosed in a community, contact tracers are needed to reach out
to all those who have had contact with the confirmed case. In the US, the
number of those tasked with that job is low relative to the amount of work that
needed to be done; and that reflects on the public health architecture that Dr
Fauci was talking about. In Nigeria, it is important to pay more attention to
the primary health care systems, and disease surveillance and notification systems.
In a WHO factsheet on primary
health care released on 1st April, 2021, (Link: https://www.who.int/news-room/fact-sheets/detail/primary-health-care ), primary health
care (PHC) was defined:
“"PHC is a whole-of-society approach to health
that aims at ensuring the highest possible level of health and well-being and
their equitable distribution by focusing on people’s needs and as early as
possible along the continuum from health promotion and disease prevention to
treatment, rehabilitation and palliative care, and as close as feasible to
people’s everyday environment." WHO and UNICEF. A vision for primary
health care in the 21st century: Towards UHC and the SDGs.”
The key words from that
definition that I want to emphasize is “ensuring the highest possible level of …
care (is) as close as feasible to people’s everyday environment.” There is need
to bring quality and equitable health care to people in their communities, and
that is what primary health care entails.
Another WHO article (Link: https://www.who.int/health-topics/primary-health-care#tab=tab_1 ) explains:
“By providing care in the community as
well as care through the community, PHC addresses not only
individual and family health needs, but also the broader issue of public health
and the needs of defined populations.”
In the WHO factsheet mentioned
earlier, the role of PHC in a health crisis was explained:
“PHC is also critical to make health systems more
resilient to situations of crisis, more proactive in detecting early signs of epidemics
and more prepared to act early in response to surges in demand for
services. Although the evidence is still evolving there is widespread
recognition that PHC is the “front door” of the health system and provides the
foundation for the strengthening of the essential public health functions to
confront public health crises such as COVID-19.”
A case study for Nigeria was “developed
by the Alliance for Health Policy and Systems Research, an international
partnership hosted by the WHO,
as part of the Primary Health Care Systems (PRIMASYS) initiative. PRIMASYS is
funded by the Bill & Melinda Gates Foundation, and aims to advance the
science of primary health care in low- and middle-income countries in order to
support efforts to strengthen primary health care systems and improve the
implementation, effectiveness and efficiency of primary health care
interventions worldwide.” (Link: https://www.who.int/alliance-hpsr/projects/alliancehpsr_nigeriaprimasys.pdf?ua=1
). The report summarizes the problems with the primary health care systems in
Nigeria:
“Summarily, the Nigeria PHC system suffers from
fragmented services, weak referral systems and poor infrastructure, and there
are serious gaps in access to basic health services.
The multiplicity of vertical disease control
programmes, with poor integration of services at suboptimal levels, results in
low coverage of high-impact, cost-effective interventions.
There is poor linkage between the different levels of
care. Materials and equipment for service delivery at the PHC facilities are
hardly available or functional.
Most health centres no longer have functional drug
revolving schemes, resulting in shortage of essential and critical medicines
and commodities at point of service delivery.
A good number of the components of PHC are not
provided at most service delivery points.
All of these challenges are worsened by professional
conflicts within the health system, and by insurgence and conflict, especially
in northeastern Nigeria. This has hampered effective PHC service delivery in
the country.”
Another critical component of
public health is disease surveillance and notification. In an article by Isere
and others on notifiable
disease surveillance and notification system (see link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518330/), the authors
highlighted the importance of this system:
“Disease surveillance is the continuous scrutiny of
occurrence of diseases and health-related events to enable prompt intervention
for the control of diseases…
However, disease notification involves the official
and timely reporting of the occurrence of specific diseases and conditions to
designated public health authorities by clinicians and other health personnel
for action using designated reporting tools. Disease notification is an important source of data
collection for an effective and efficient disease surveillance system.
Disease surveillance and notification (DSN) have been
recognized as an effective strategy for the prevention and control of diseases
most especially epidemic prone diseases.”
The article by Isere and
others (mentioned above) gave a schema of reporting notifiable diseases and
getting a feedback. I adapted it here:
Health facility (Clinician and
Health facility focal person)
↓↑
LG DSNO (Disease Surveillance & Notification
Officer)
State Epidemiologist/State DSNO
↓↑
Federal MOH (Ministry of
Health, Epidemiology Division)
↓↑
WHO (World Health
Organization)
Keys: ↓ (reporting) ↑ (feedback)
As seen above, the disease surveillance and notification
systems are intrinsically linked with the primary health care systems
highlighted earlier. Rather than simply focus much resources on top-class
health facilities that will serve the few, there should be more focus on addressing
the issues at the heart of the primary health care systems that serve the
majority of the population in Nigeria.
So far, in this part 2 of the series, I’ve written about the need for
government and governmental authorities at all levels to have constructive and
robust interactions with the people about their policies and plans before
implementing them. The people need to be engaged and involved for public health
measures to succeed, and this can be achieved by bringing on board opinion
leaders, traditional rulers, religious leaders and community heads. Let us not
forgot some of the vital lessons that COVID-19 has taught us. I also talked
about the need to pay more attention to the primary health care systems in the
country. There are still more key points that I will write about in the next
part of this series. Really looking forward to that.
To be continued...
Written by
DR EUGENE AKPONOJIVI OJIRIGHO
CONTACT INFORMATION:
Email: eugeneojirigho@yahoo.com;
dreugeneojirigho@gmail.com; dreugeneoji@gmail.com.
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