Dr Rimini K Machunga of the Department of Family Medicine @ Dalhatu Araf Teaching Hospital (DASH) in Lafia, Nasarawa State offers original ideas on what needs to be done!
The Covid-19 disease is a wake-up call to fix our health care systems and bring about the original design of Prof. Ransome Kuti who understood the true value of the Primary Health care system.
If the Nigerian government continues to play the role of the ostrich or continues to pay lip service to the health care crisis, then we should really be sorry that the advent of Covid-19 and the suffering that it brings to us will all be in vain. But if we turn things around and apply even common sense as well as scientific rulebook, then we should be glad that Covid-19 made a positive impact on our generation and the generations to come in spite of the price we would have paid. This piece is about my justification for this belief.
Since the news of the Novel Virus showing up in Nigeria, many Tertiary healthcare institutions began to take proactive measures to minimize the risks of contracting and propagating the virus. In doing this, they have largely followed the reasonably logical idea that if a person suspected of Corona virus develops symptoms, such a person should be placed in isolation within a tertiary facility or an approved private facility. Such a person would be a traveler from a country where Covid-19 is present or a person that had close contact with such a person. Such a person would be expected to undergo self isolation and if any symptoms developed, he or she or they were to contact the Nigerian Centre for Disease Control, (NCDC). They would be placed in an isolation center, according to the established protocols and judicious use of PPE, for close monitoring and treatment. This aims to limit the spread of the virus to the community level.
Another case scenario and all the more likely, especially now with the evidence of community transmission, is that an unsuspecting person would visit the hospital just as any patient would. Such a person would present via the GOPD (general) or any of the outpatient clinics where they are already patients on follow up such as the MOPD (medical), SOPD (surgical), ANC (prenatal), Gynae Clinic, POPD (paediatric), ENT, Eye Clinic or Dental clinic, NHIS, STI, Family planning clinic , etc.
If such an unsuspecting person is in a very bad condition such as traumatic injury, a medical or surgical emergency, such a person who unknowingly has Covid-19 but is either asymptomatic for Covid-19 virus or is suffering from exacerbation of his underlying illness brought on by this Novel virus, they will be attended to in the Emergency or Casualty department together with other undifferentiated patients. Now, it is this unsuspecting case scenario that will pose a huge threat to our already fragile healthcare system.
The government cannot play the role of the ostrich hiding its head in the sand telling the public that they never realized how bad the healthcare system is and has been, and will continue to be. Otherwise, they should explain why the president treats ear infection with Vitamin C in London. The whole world is crying out for lack of PPE because they have run out. “Shit-hole countries” such as ours, never had them in the first place! The N95 masks, visors and disposable gowns are foreign to us. The average healthcare worker has never before seen them let alone worn them. The N95 mask, for example, needs to be fitted individually by a professional fitter. Even if provided, without training and retraining and proper supervision in the donning and doffing of these, the PPE will constitute a hazard much more than not having them at all. But we must start from somewhere, and that is the provision of the PPE, which, unfortunately, has not reached the frontline healthcare workers while we see administrators and big shots wearing them all over the place.
One of the positive steps taken by many hospitals is to close down the clinics that must see their patients in very close proximity, such as the Dental, Eye and ENT clinics, save for emergency situations.The other clinics have limited the number of patients to be seen per day. For example the GOPD of a particular hospital sees only 50 patients per day instead of the usual 120 patients per day. This same GOPD recently went further to rotate their doctors such that they do not all come to clinic on the same day. Two groups were created such that they are at work on alternate days. This is aimed at limiting the number of doctors who would be exposed to an unsuspecting case, so that if the case is determined to be suspect after adequate consultations, less healthcare workers would need to be placed on self-isolation and there would still be other doctors and health workers to attend to patients. The other gain of this strategy is to conserve the much needed PPE so that less is used up per day by the health workers on duty.
The down side of this strategy is that more staff are left redundant on the days that they do not come to work. And even those coming to work attend to far less number of patients than they would and could have been happy to attend to.
This results in fewer patients and clients receiving the needed care for their non-Covid-19 ailments and problems. In turn, morbidity and mortality are expected to rise in the non –Covid-19 patients. They become victims of the remote effects of Covid-19. On CNN some days back, it was reported that, in New York alone, 3000 non-Covid-19 patients died in one month as a result of their inability to access health care services since virtually the entire health care systems in New York are overwhelmed with Covid-19 patients.
In Nigeria, we have enormous morbidity and mortality rates even before the advent of Covid-19. Infectious diseases such as malaria, Lassa fever, diarrhoeal diseases, tuberculosis and pneumonia constitute one category while non-infectious diseases such as hypertension, diabetes and cancer constitute another. Add to these, deaths and disability from road traffic accidents, armed robbery attacks and terrorist attacks. Add to this too others such as manslaughter by ignorant religious leaders who pray away illnesses and cast out diseases, usually for a fee called “offering”. Then add ritual killings as well as killings by security forces. The day security forces killed 5 persons in Kaduna State in the name of enforcing Covid-19 lockdown, Nigeria recorded only 5 Covid-19 deaths. It is clear that we have more than enough reasons to die in Nigeria besides Covid-19. What about the poverty and malnutrition that is so endemic in Nigeria. How do citizens feed well let alone purchase medication or pay for necessary investigations to ascertain their health status? How far does health insurance go?
In order to minimize the adverse effects of Covid-19 lockdowns and the scaling down of services in major health facilities, health care workers need to be recruited into the Primary Health Centers of the various districts of a state. Only a select group of Covid-19 -trained health care workers may remain in the tertiary facilities to serve the few patients that need emergency tertiary services in this era of Covid-19 as they anticipate the index Covid-19 patient and the subsequent ones to come. Only as these select groups of trained workers become overwhelmed from work, or go into isolation or die because of the virus that other doctors and allied professionals will be recruited from their secondary places of assignment and trained to fill in the gaps as Covid-19 cases increase.
The benefit of deploying our healthcare workers to the PHCs is to be able to continue to render the usual pre-Covid-19 services to the people close to where they live and work. In this way, communities can be locked down instead of individuals being locked down in their homes. If people are not allowed to leave their communities, the healthcare workers deployed to these communities can serve as surveillance officers of Covid-19 while rendering their usual services. In this way, the people are served. Community policing becomes even more relevant in maintaining community lockdowns. The doctors and allied health professionals are fully engaged and not made redundant. Even the dentists, ENT surgeons and ophthalmologists were all general doctors prior to specializing. We would still ask them to withhold their specialized services unless an emergency presents because of the added risk from very close proximity involved in their line of work. Everyone can be recruited to serve in the communities as a general physician in this Covid-19 era. Because the health care work force is closer to the communities, even home based care can be offered to people who cannot make it on their own to the PHCs. The aged and the disabled would stand to benefit the most. So also the community chiefs, emirs and their families who may feel too big to attend a Primary Health Centre, (PHC).