Professor Chima Onoka is a community physician and health systems economist. In this piece, he shares his thoughts about the ongoing COVID-19 pandemic in Nigeria and highlights specific strategies to adopt NOW given a forecast challenge, the return of the more mobile population group to the streets and the exposure of the elderly.
“…hunger will kill us before the virus does”
In an earlier article on 23 March 2020, I made the case that Nigeria needed to act urgently and deliberately on an inescapable and already established war with COVID-19. Blame, denial and fear-induced paralysis were needless. Before Nigeria’s army was commendably and purposely ‘empowered’, the virus hit the country’s heart, ‘Aso Rock,’ and the government houses in two states of Lagos and Ogun.
Those painful events represent tactical upsets in a war between humans and the dreaded virus. As of 20th April 2020, the deaths recorded globally by the World Health Organisation mirrored having 1,000 domestic airplanes carrying 157 persons each, crashing and killing all on board; all attributable to the dreaded COVID-19 infection.
Thankfully, Nigeria’s Center for Disease Control (NCDC) is doing all it can to mount a response with the support of the federal and state governments, partners, and relevant stakeholders.
While NCDC focuses on the health component of the response, the social services and humanitarian sectors need to warm up to an imminent problem, that is, citizens flooding into the streets, not with dead bodies, but in search of food and a source of living. Doing so requires the activation of unique context-sensitive strategies now, not at the end of the lockdown. The stakes are high, but the possibilities inspire hope.
In many Nigerian cities, and painfully so, only the elite and part of the middle class are on lockdown. The majority of the citizens, the ‘masses,’ are interacting daily in the streets, oblivious of the infected, driven out by hunger, their main enemy, to find food for their households, or the means to obtain it.
The ‘poor masses’ seem not to have seen or touched the food promised by government authorities.
The poor may even be more than we know, given that Nigeria is ranked 152 of 157 countries in the World Bank’s 2018 Human Capital Index. Also, 43% of Nigerians are either unemployed or underemployed. Most Nigerians are uncertain of an income this April and the months ahead.
The middle-class citizens, currently consuming their business capital, may have very little left at the end of April, and many will need the freebies for the poor. At the household and country levels, economic indices have gone awry. Hospitals are shutting down, with entire staff getting isolated after exposure to COVID-19.
Deaths and severe diseases from confirmed cases have been less in Nigeria and other sub-Saharan African and developing countries.
They have a comparatively lower proportion of the elderly population, and most live in rural areas, further away from airports, the major source of importation of COVID-19.
The core cosmopolitan areas are still the foci of current testing efforts. However, through local transmission, COVID-19 is gradually walking its way to those areas, slowed mainly by a population-based prevention strategy in place; a lockdown.
To minimize the impact, the government promised to distribute food and/or money to the poor.
Can the government sufficiently respond to the public demand for food and social support in the medium to long term? Nigerians do not think so.
Not for the lack of desire, but because the required fundamentals for implementation are not really in place and are difficult to set up in such an emergency.
Simply put, the existing social support system is constrained in data, strategy and stakeholder trust and support needed to make it work. Additionally, productivity and the local economy across most sectors are too dependent on the daily manual effort of those on lockdown.
What can we do now?
Anticipate and prepare for a shortened lockdown period:
Is lockdown the best strategy for countries like Nigeria? I would say yes and no.
Yes, in the short term in order to minimize importation of the virus, organize an emergency response, ask for technical and donor support, decide who signs the cheques and releases funds, organize the health system or make ad-hoc preparations, procure equipment and supplies, mobilize existing health institutions, train their health workers, trace infected persons, isolate and treat the sick, and keep citizens in one place to reduce confusion and community transmission.
In the medium to long term and I mean beyond one month, the social conditions are different. Hence, my answer is no.
It will take more than a miracle to achieve in Kano for instance, hence the urgent need for urgent implementation of mass prevention strategies, and investment in protection of health workers. Even more-developed countries are realizing this. Again, enforcement in Nigeria by security agencies often means arresting people. This is not a solution; detention in police cells and correctional centres is not an option.
Prepare the younger and more mobile population for the inevitable:
Nigeria’s population is among the youngest globally. In the communities where the majority reside, the younger population is already in the streets as earlier described, compromising the objectives of physical distancing.
Our best strategy now would be to quickly prepare and equip them for life in the workplace, streets and at home, in a period of COVID-19 pandemic.
Much of this group, a lot of who have or may be infected, will develop some immunity and will better cope with the infection based on existing knowledge.
For many, it will not look different from the flu they are used to. But some people will get sick and have to be cared for at home with support from hospitals, or in the fragile health institutions and care centers, for those with more severe conditions.
Nonetheless, they need to be engaged to slow down community transmission, especially by equipping them with information at the grassroot level, face masks (no gloves), and handwashing supplies, as they inevitably return to the business of looking for food for themselves and their loved ones. For the healthworkers it will mean living in protective gears in the workplace.
Target and protect the more vulnerable elderly:
A corresponding strategy would focus attention on Nigeria’s elderly population of about 8 million people. According to the Population Division of United Nations’ Department of Economic and Social Affairs, they represented 24.7%, 21.5% and 23.9% 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% and 4.5% (8.6 million), respectively .
Better simplified, the ratio of elderly persons in Nigeria compared to Europe is about 1:5, implying that the proportion at greater risk of severe conditions is much less.
These citizens need protection from the more mobile people using every prevention strategy possible including physical distancing until transmission wanes and herd immunity develops over the few months ahead. Currently, this population is less recognized by Nigeria’s healthcare and financing system and are the main group that will challenge the health system.
Prepare for an early switch from contact tracing:
Given Nigeria’s demographic pattern, the policy options are whether to keep hunting for contacts among 200 million people mingling in the streets or to build a prevention strategy that focuses attention on protecting the most vulnerable, especially the elderly. In the management of an epidemic such as this, contact tracing is also not beneficial at the peak of transition.
When physical distancing is impossible among the masses because of hunger, contact tracing becomes inefficient and one must prepare for the inevitable. The consequences of the contrary hypothesis are not desirable, which are avoidable social unrest, escalation of insecurity and uncontrolled expansion of transmission.
Overall, while progress has been made in response to the COVID-19 pandemic in Nigeria, the country needs to prepare for the inevitable flooding of the citizens into the streets now, not at the end of the lockdown. The strategy needs to ensure the protection of the elderly and the preparation and equipping of the mobile younger citizens whose entry into the streets in search of means is already advanced, and as always, consistent prayers for guidance and courage.
Prof. Chima Onoka, a health systems expert and health economist based at the College of Medicine, University of Nigeria Enugu Campus