Prepare for the inevitable, now!

April 22, 2020
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ON 23rd March, I raised several issues that needed urgent attention in a message titled, “It Is Wartime…a call to action against COVID-19 in Nigeria”. It became necessary to have a follow up to that article. As we all know, millions have been affectedglobally, economies have crashed, and the crisis has only been compared to the second World War. While glimpses of hope swell from the seeds of stories of people recovering from the illness, the shadows of uncertainty, fear, disease and death still hover around households and nations. As of April 14, the deaths recorded by the World Health Organisation mirrors having585 planes carrying 200 persons each, crashing and killing all on board, all because of the dreaded COVID-19 infection. A generation (especially the elderly) is threatened. According to the United Nations Department of Economic and Social Affairs, Population Division, they represented 24.7 per cent, 21.5 per cent and 23.9 per cent of the population in Europe, USA and United Kingdom, respectively, in 2017 compared to the figures in Sub-Saharan Africa and Nigeria, which was 4.8 per cent and 4.5 per cent (8.6 million), respectively ((2017).It is very possible that Nigeria and other sub-Saharan African countries have probably not seen a lot of deaths and severe disease because they have comparatively less proportion of the elderly population, and the majority of the elderly live in rural areas, father away from airports which were the major sources of entry. However, through local transmission, COVID-19 is gradually walking its way to those areas.

As stated in my earlier article, a lockdown as a physical distancing measure, must be accompanied with social support for it to last long enough anywhere in the world. In Nigeria, a lockdown is in place, though in a differential manner across states. The ills of staying at home without social support has become obvious too, a surge in crime and civil unrest, which is a time bomb. It is not reliable beyond a few weeks because such a social system is not structured to provide social support in a significant manner in normal times, and much less, in an emergency. Nigeria, and indeed sub Saharan Africa must now prepare for the inevitable…citizens pouring into the street, not with dead bodies, but in search of foodand a source of living.

Like in many sub-Saharan African countries, Nigeria’s testing and treatment effort(by population density) has focused on the more urban andcosmopolitan cities of Lagos and Abuja. While the impact of the COVID-19 Pandemic has been more on the elderly, majority of this group are in the more rural locations, where the virus is gradually progressing to, having reached several states. This population is less known by the Nigeria’s health care system, including through the National and Private Health Insurance schemes.

This article examines key progress made in Nigeria generally and highlights specific strategies to adopt NOW in view of a forecasted challenge, namely,the return of the more mobile population group to the streets and the exposure of the elderly. The attention on the elderly is important because, while the rest of the population can more easily cope and develop immunity, the elderly in Nigeria are at more risk of severe disease and deaths, are more likely to have co-morbid conditions, will put the greatest demand on a dysfunctional health system if nothing deliberate is done, and have to be provided with care. The leaders must be bold to take the right steps that are context-relevant and should do so in a timely manner.

A quick review of progress

Since the earlier article was published, diverse progress has been made in various aspects by the government and citizens. 1.PUBLIC RESPONSE: The government has commendably put its best foot forward in the battle and has also laudably embraced exposure to public scrutiny. Specifically, the Nigeria Center for Disease Control, supported by the Presidential Task Force and development partners, has made progress in testing, establishing care centers, deploying human resources, and providing updated information to citizens.Donations have also come in and government funds are being reprogrammed. Nonetheless, given our context of federalism, challenges have also emerged in the coordination of local subnational action in a time of emergency, especially one that requires unified adoption of some strategies.  2.The health system: Everyone has also noted that the health system is fundamental to social existence, as its failure exposes the vulnerability of all aspects of life, including family, faith, government, education, communication, arts (including entertainment and sports) and economics (including business, science and technology). Citizens, and more especially, the elite have realised that “there is no place like home,” and that in a globalized environment, a proclivity to emigration, medical tourism, and disinterest in local governance and accountability does not provide physical, mental, social or spiritual security.

  1. Citizens: The National Assembly (the elected representatives of the citizens), the media, non-governmental organisations, professionals, faith-based organisations, civil-society organisations and the private sector have appreciably stepped up their engagement with the threatening reality. Despite their reservations about the effectiveness of public systems,the resilient “ordinary Nigerian” has cooperated to a reasonable extentin adopting new cultures – to worship at home, reschedule burials, weddings and similar events, to consume savings and business capital on food, to pray for the government and health workers, and to show love to their neighbours,despite having limited resources. 4. Intellectual community: The research ecosystem, educational institutions, professional groups and health infrastructure have been exposed as having immense potential but being unengaged, unmotivated,unprepared, neglected, trailing in adoption of technology, poorly funded and unorganized in a way that can reasonably support a Nigerian State in need. Opportunities exist but require intentional analysis, understanding and engagement of these and other stakeholders.

What strategies will be needed now and why?

  1. Emphasize primary prevention: This holds the key to any sustained effort and has been well discussed. What is left is the need to rapidly provide quick and soft loans to the small-scaleentrepreneurs waiting to engage in productive ventures occasioned by the outbreak…and these exist across all sectors of the economy.

In addition, households need to know how to use facemasks, not whether or not to use facemasks (including home-made masks). The reasons are simple; people are coming out soon to become productive, asymptomatic people are transmitting COVID-19 even as they talk, no one really knows who is infected and infection needs to be slowed down for population immunity to grow without putting excessive pressure on the inadequate health infrastructure, or risking the lives of the elderly at home.

  1. PROTECT THE ELDERLY: The best-case scenario to achieve this will be to completely protect our elderly from the younger, productive, risk taking and mobile population and care for them through this period (some months) for transmission to wane. This appears unrealistic. The minimum strategy to adopt will be for every household to do all it can to protect their elderly until this is over…and that means adopting all preventive measures including keeping any exposed person from them, anyone with symptoms, not allowing anyone serve them without hand washing, applying physical distancing measures, and even keeping children away (remembering that children who appear to be least vulnerable, are the most mobile and can carry the virus especially through fomites). The elderly must also apply wisdom and insist on use of preventive measures by anyone coming to them…especially handwashing, use of sanitizer, and masking where possible. They need these measures the most.
  2. PREPARE THE REST OF THE PRODUCTIVE POPULATION FOR THE INEVITABLE: Many citizens are already exposed, infected, untested and cannot be tested in the medium term because of limited kits and resources. This is situation is not peculiar to Nigeria. Those with symptoms have moved on, having considered it a common flu. They have also developed some immunity (even though it is still unclear how long this will last). This group inevitably have to become productive again and will be coming out for food and income. The time to get them ready… with information, facemasks, sanitizers, home based prevention and care information and kits, motivation, entrepreneurship opportunities and finance (example to become producers of masks) IS NOW, NOT AT THE END OF THE LOCKDOWN. Departments and Agencies of Government and other organisations with responsibility to do this should be shaken out of paralysis, NOW.
  3. MOTIVATE HEALTH WORKERS: The Government must lead the effort to motivate health workers, not based on “compensation” as it is wrongly labelled, but appreciation and motivation (such as using financial and hazard insurance incentives where possible). Citizens must take responsibility for this as wellby supporting health workers at all levels with kindness. The scope is wide; provide food items, make masks based on the advertised standards and donate to them, share a prayer or kind word, put a call through to their spouses and households left at home for the war front. Everyone can do something, can do it today and can do so NOW!
  4. PREPARE ALL HEALTH FACILITIES: Owners of health facilities ought to respond in a more deliberate way to the crisis. Progress will be restricted if everyone with a symptom anywhere in Nigeria has to call the NCDC lines, especially with the transmission getting decentralized. Every health facility needs to have a phone to receive calls from their registered patients (at the least), and some beds dedicated for the very sick. They still need to form the majorscreeningpoint, and need to activate m-Health technology, even at its most rudimentary form. Working on site or from home, staff can use phones to counsel clients, respond to questions, provide care, guide clients to sites for medication pick-up, and provide follow-up support. It is well known that lots of health conditions for which people seek care could be handled if ill persons had a health worker to speak to first, and early enough. A hospital phone makes this possible.
  5. PREPARE WORSHIP CENTERS: Worship centers have reasonably cooperated with the government’s directive. Students of social systems also know the intricate connection of faith to other social activities in Nigeria including weddings, burials, and similar risky gatherings. Citizens that speak ill of worship centers are probably ill-informed of their value in the Nigerian society. It needs to be emphasized that such centers, provide hope for life today and beyond this sorrow-filled world, which the world does not and cannot provide as is obvious today. Secondly, such centers, the right ones, fill up what the State does not…compassion, physical, social and psychological support, and are currently bearing an unquantifiable amount of the supply of food to households. These ones deserve commendation for their response in meeting citizens’ needs currently and not vilification. Moreover, the role of faith in health cannot be under-emphasized. and Nigeria is a nation where the impact of faith on societal wellbeing is established.
  6. MULTISECTORAL COLLABORATION: To achieve the collective objective of health and social security, and to minimize the economic impact of the crisis, a multisectoral approach is necessary. Those in health including the departments and agencies of government, health education and research institutions as well as professional groups, need to back the NCDC and the Federal and State Ministries of Health. Others sector including the housing, power, agriculture and nutrition, law enforcement agencies, human rights, finance, media and manufacturing sector. The collaboration must be in a supportive rather than a competitive manner, should adopt a human capital approach, and allow constructive and respective engagement. While emergency supplies may have been important to last the next few weeks, the local entrepreneurs must be empowered now to produce the supplies needed in the coming months.

Overall, while several commendable efforts are ongoing across the country, it is imperative that Nigeria adopts context-relevant strategies that will help it survive as a nation, given its peculiarities and opportunities. The time to do so is now, and not at the end of the lockdown. The elderly must be in our hearts for us to have a robust strategy, and the more mobile and more massive population group must be prepared for their release with a sense of urgency.

  • Professor Chima Onoka, a community physician and health systems economist, writes in via: chimaonoka@gmail.com

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