COVID-19 pandemic in Nigeria, why lockdown is the hard way and the only way.
By Dr Sani Musa, MBBS (ABU), MTID (LSTM), FPMCpaed write on 1st April 2020
It is no longer news that COVID-19 pandemic has reached the shores of Nigeria and has so far affected eleven states plus FCT. At the same time, there seem to be a widespread misunderstanding by the Nigerian public of the implications of a full-blown COVID-19 outbreak which could negatively affect the country’s response. COVID-19 is a new disease that is not well understood and countries, therefore, rely largely on the experiences of afflicted countries to inform their interventions. Since Nigeria is facing this infection for the first time, only time could tell whether the country is going to experience the milder, same or worse form of the disease. It is, therefore, critical for the government to be proactive and prepare for the worst. As for the public, they need to fully comply with outlined government interventions. In issues of life and death, it is always better to err on the side of caution, no matter how extreme it may look. Taking the Nigerian context into consideration, this article attempts to postulate the possible dire consequences of a full-blown COVID-19 outbreak in the country. It also proffers some realistic recommendations for the Nigerian government and the general public.
First, the experience from China, Italy and other affected countries has shown that everyone could be infected with the virus. However, while it could infect anyone, the disease takes a higher toll on the elderly and those with coexisting illnesses such as diabetes, HIV infection, asthma, hypertension and chronic kidney disease. According to the latest WHO statistics, Nigeria has about the same prevalence of these coexisting sicknesses and could even have higher because of underreporting of cases. The underestimation of the cases is partly due to poor health-seeking behaviour of a significant number of the populace and the corresponding weakness in our health reporting system. For the same reason, Nigerians with coexisting illnesses could be poorly controlled compared to those living in developed countries whichwill predispose them to greater risk of severe COVID-19. Moreover, our younger population may not be as healthy as the ones in the developed nations. A significant number of Nigerian children of them are undernourished which could predispose them to severe disease.
The corona viruses are a family of virus that characteristically causes mild illnesses such as the common cold. However, from time to time new species of the viruses do emerge and cause severe disease in humans. Examples of the severe forms are the Severe Acute Respiratory Syndrome (SARS) pandemic which took place in 2003 and started from china and the Middle East Respiratory Syndrome (MERS) first reported in Saudi-Arabia in 2012. Late in 2019, a novel specie of these viruses emerged in city of Wuhan China and rapidly spread resulting in a global pandemic and causing severe form of the disease in some cases. The virus was spread to other continents mainly by importation through air travels. The new virus was named SARS-COV-2 and the disease referred to as COVID-19. The virus is transmitted when suspended viral particles in the air from an infected patient are deposited on eyes, nostrils, and mouth or even swallowed. These viral particles could also be deposited on inanimate objects and surfaces where it remains viable for up to 24 hours or more depending on the surface. More disturbing, is the possibility that the virus could remain suspended in the ambient air for up to 72hrs, during which it could be transmitted. Now, looking at the typical Nigerian setting; the crowded worship places, schools, motor parks, markets, slums with overcrowded rooms, one will not help, but see a fertile ground where COVID-19 outbreak could propagate.
The most worrying aspect of the COVID-19 is its potential to shut down our healthcare system. Firstly, a good number of our hospitals are designed and sited without prior consideration for the control of infectious disease and do not have functional isolation facilities. This implies that, if there are cases of COVID-19, the hospital itself may serve as a breeding ground for its transmission. When the disease is transmitted to a healthcare worker, they take ill or at least become a contact of a COVID-19 patient and have to go on quarantine.
This is almost inevitable, given that when a COVID-19 patient walks into a typical Nigerian hospital for the first time, he/she will have to mingle with virtually all the hospital staff. These include the security personnel, the cashiers, record officers, nurses, doctors, pharmacists, phlebotomists, and of course the patients infected samples go to mingle with the laboratory staff. This is in addition to mingling with other patients in long poorly organised queues at every point mentioned above. These other patients and visitors could be infected and take the virus back to the community and reinforce the cycle of transmission.
Now, supposing the index patient has contact with only one healthcare worker at each of the points described above, the implication is that, at least six healthcare workers have to go on quarantine. This means that these workers have to be away from their place of work, with nobody to replace them due to the chronic shortage. By the time you have ten of such patients, then you have to send sixty staff out of the hospital with no replacement. In fact, the experience with the Ebola outbreak was such that, once a few suspected cases were recorded, some healthcare workers panicked and abandoned their duty post. Thus, the consequence of this is that, as few as fifty COVID-19 cases are enough to shut down or severely overwhelm any of the Nigerian tertiary hospitals.
By the way, we should make no mistake thinking that, healthcare workers will be guaranteed protection at this time. First, corona virus (SARS-CoV-2) can be transmitted in the early stages of the disease (COVID-19), whence such patient may casually walk into the hospital with symptoms as mild as the common cold. Healthcare workers only wear the full complement of personal protective equipment (PPE) (such as facemask, gloves, aprons, googles, gowns etc) when confronted with a suspected or confirmed cases of a contagious diseases. They cannot always be in the full PPE because of the discomfort associated with wearing it and more importantly, the cost of its purchase. As a matter of fact, this pandemic has made them extremely scarce even in countries that manufacture them. Perhaps, the current scarcity is best illustrated in the recent suggestion by the US president to disinfect and re-use facemasks. These PPE are disposed off after every use; hence, they could be exhausted very quickly in the face of severe global scarcity and in Nigeria, a country that does not manufacture them.
Additionally, COVID-19 patients do not share things with the other patients so as not to infect them. This implies that they have to have a dedicated ward, dedicated doctors and nurses, and in order to cater for those with the severe form of the disease, there has to be dedicated intensive care units, ventilators, dialysis machines, and so on. Practically, this means creating a five-star hospital within the existing hospital, and in the case of Nigeria, where one hardly existed. When we saw China build a new hospital in Wuhan within days, it was not necessarily because their existing hospitals did not have enough space to accommodate the patients. Their aim was to avoid infecting other patients with the virus. Again, converting stadia and other places to isolation facilities may seem a good idea, however, the question remains as to where to get the staff to man those places. Already there is a shortage of healthcare workers in the country, no thanks to the alarming exodus of doctors and other healthcare workers for greener pastures in recent times. Further, when it comes to intensive care, most Nigerian healthcare workers do not have the requisite skills and experience, particularly with the use of gadgets such as ventilators and the likes. Aside from this, our healthcare system at the moment will hardly accommodate ventilators. The constant electricity as well the ample oxygen supply required to use them are difficult to come by or simply not available. Perhaps all you need are five patients on continuous high flow oxygen for a week and all the oxygen available in a Nigerian tertiary hospital is completely exhausted. Now, COVID-19 patients that are critical will require oxygen and in fact some are being discharged home on oxygen in US at the moment.
Another potential problem is that of poor testing/testing low number of cases because of the scarcity of test kits and specialised laboratories. This implies that many COVID-19 cases will be walking in our midst unconfirmed and continue to spread the virus. While the general public could carry on its usual business due to blissful ignorance, this will contribute to the panic by the health care workers, and possibly, abscondment from duty post.
Consequently, one of, or all the above reasons described could easily cause healthcare system breakdown in a matter of days. When this happens, healthcare workers will desert the hospital and the hospitals will not be working. This is where the real calamity of COVID-19 will manifest its ugliest face; When all emergencies, simply become automatic deaths. When Patients with HIV and TB who go to the hospital to obtain free drugs will end up dying from this condition helplessly at home (they can neither access the drugs nor buy them). When patients with chronic illnesses that depend on regular hospital visits to survive such as those on dialysis, hypertensive patients, diabetics, asthmatics and the likes will simply perish at home. These are just a few scenarios to illustrate what healthcare system breakdown entails, but it is much more complicated than we can imagine.
As grievous as this sound, it is not hard to imagine the consequences. It happened during the 2014 Ebola crisis that took place in some West African countries. During the disaster, much more patients died of other diseases than those who died of the Ebola itself. Patients with emergencies that were used to be rushed to hospital before Ebola were left to die on their own and in some instances, their corpses littered the streets. Perhaps the only potential difference between the Ebola catastrophe and the potential COVID-19 calamity will be that Ebola crisis was limited to West Africa which gave the rest of the world the wherewithal to bring in their support. In present COVID-19 pandemic, some of those countries are, unfortunately, already overwhelmed by their own crisis. Furthermore, the global economy is already in recession and there are acute shortages of medical supplies. With a clear trajectory where the stronger healthcare systems in the world are being overstretched, Nigerias healthcare system could easily be overwhelmed should COVID-19 outbreak become full-blown.
To avoid this, quick, frantic and comprehensive measures have to be put in place. Since this illness was imported through the airports, lockdown is the most potent measure of preventing the infection from entering our population. Thankfully, this is already being implemented. However, it needs to be countrywide and coordinated. It needed to have been instituted early enough before a critical number of cases are reached. Once that number is reached, a vicious circle of community transmission will be ignited which will in turn quickly trigger a cascade of events that will rapidly breakdown hospitals and bring the countrys economy to its knees. Indeed, history is there to remind us that pandemics have shattered countries in the same way or even worse than they could be ravaged by war.
However, public health related interventions normally succeed when contextualised to specific settings and the perceptions of the local populace taken into consideration. Consequently, while partial lockdown such as closure of schools, stadia and overcrowded worship places should subsists while the pandemic lasts, the complete lockdown ought to be intermittent. Perhaps a period of complete lockdown of four to five days (to include Friday, Saturday and Sunday) should be followed by one or two to four days of ease. This will enable poor masses that live from hand to mouth to look for food and the retail shops of basic needs to re-stock before the next cycle of complete lockdown. It will also provide avenues for dissemination of information concerning the pandemic such that more people are carried along. It will further enable the attendance of hospitals for routine services and wellness clinics such as the vaccination clinics for children. Again, it will serve as a golden opportunity to teach the public practically how to observe physical distancing, hand sanitation before and after entering public places, tricycles, taxis etc. The complete lockdown period on the other hand could be used to disinfect public places. Throughout this period, however, government should also look at how to provide food for the extremely poor and those whose jobs are directly truncated.
Importantly, all hands must be on deck to defeat this virus and every responsible citizen needs to play his part. The least one could do is to stay at home, observe physical distancing, wash hands more often and propagate the message. It is no time for lamentations, rhetoric, conspiracy theories and blame game. When your house is on fire, the first thing to do is quench the fire first before you start discussing what caused the fire, if at all, you need to.
At this material time, it is gladdening to see that the philanthropists, private sectors, non-governmental organisations and politicians have started supporting the government in this fight in various ways. This is a welcome development and ought to continue even after COVID-19 pandemic. Perhaps the unused funds/left over funds could be converted to a dedicated fund, handed to trusted individuals or foundations and used to revamp the countrys ailing healthcare system. This will help to tame the tide of medical tourism and brain drain in the health sector which has been draining the countrys material and human resources. Finally, remember to check on your neighbour and share your food while the lockdown lasts. Keep us alive, stay at home!
Dr Sani Musa, MBBS (ABU), MTID (LSTM), FPMCpaed.
Infectious Diseases Unit
Department of Paediatrics,
Ahmadu Bello University/Teaching Hospital, Shika-Zaria,