March 3, 2020

Lassa fever, cholera, meningitis, Covid-19 in Nigeria: The way forward

Hospital shuts down 3 wards as 4 doctors test positive to COVID-19

By Casmir Ifeanyi

EARLY January this year, the Association of Medical Laboratory Scientists of Nigeria, AMLSN, predicted the outbreak of three periodic diseases in Nigeria, namely: Lassa fever, Cholera and Meningitis. Stressing that the Lassa fever scourge and other epidemics are as a result of the poor, neglected and relegated medical laboratory services structure and infrastructures across the country, the association raised the alarm that even the tertiary health institutions are unprepared and ill-equipped to cater for emergencies arising from the diseases. The outbreak of Lassa fever few weeks thereafter confirmed as true one of the predictions.

Long before the National Centre for Diseases Control, NCDC, came to the nation’s rescue, only the Irrua Specialist Hospital laboratory had a semblance of capacity for Lassa fever diagnosis. Cases beyond the Irrua Specialist Hospital were referred to Senegal and other smaller countries within West Africa for confirmation. The NCDC’s robust efforts at establishing emergency outbreak centres and further scaling up the number of public health laboratories with capacity for Lassa fever diagnosis from one to five in Nigeria is commendable. However, the five laboratories are grossly inadequate to cater for a disease that is largely Nigerian in origin and which now pose a risk to our over 200 million population.

As we grapple with Lassa fever, we must be on the lookout for the imminent seasonal outbreak of cholera and meningitis. Nigeria has a checkered history of these diseases, and our health system for want of preparedness is always overwhelmed during their outbreaks. Though they are vaccine preventable, cholera and meningitis claim lives en mass in Nigeria. Unfortunately, as has been the case with Lassa fever, so also it is that most medical laboratories, even in the teaching hospitals and federal medical centres, lack the requisite facilities and the resources for diagnosis of cholera and meningitis.

Moreover, Nigeria is blessed with abundant medical laboratory scientists who have the training to manufacture the vaccines, but those at the helm of affairs have continually sabotaged the efforts at vaccine production locally because of the huge gains they derive from vaccine importation and racketeering. The overall consequence is the constant high mortality occasioned by these diseases because the vaccines are usually out of reach of the average at-risk Nigerians.

The global health index score of a country is a reflection of the country’s value for the lives of the citizens, health infrastructure, health policies, and the drive to implement them. Nigeria ranks at the bottom of 10 globally, and the country is considered largely unsafe on account of its global index score in 2019. Out of a top score of 100, our indices score for health system is a mere 19.9; Prevention 26.3; Risk environment 33.7; Response 43.8; Detect 44.6 and Best practices 56.7

It was on this basis that the AMLSN in 2019 organised the first ever international conference on global health security in Nigeria, which had the Vice President, Prof. Yemi Osibanjo as the special guest of honour represented by the Minister of Health, Dr. Osagie Ehanire.

At the conference, experts from across the globe, including those from the Centre for Disease Control Atlanta, USA, urged Nigerian government to take all necessary measures to strengthen its weak medical laboratory system in order to promote the health of Nigerians.

The priority action steps recommended for Nigeria include the need for governments at all levels, policymakers and enforcement agents to strengthen and implement effective strategies on biosafety, biosecurity and bio-risk, onshore and offshore, to checkmate the ever increasing highly contagious diseases outbreaks that can move across national boundaries with ease. Ultimately, government was urged to promote integrated national medical laboratory network. But government is yet to implement any of the above, and the consequences are rife.

Fears over lassa fever, cholera and meningitis apart, today, Nigeria is one of the 13 countries in Africa on the WHO watch-list for the Corona Virus epidemic. Concerns persist that not much is being done to build capacity of the Nigerian health workforce, especially in medical laboratories in the diagnosis and containment of the ravaging corona virus epidemic that has claimed lives of hundreds, and well over 20,000 persons infected in China, the US, and other parts of the globe. Nonetheless, it is reassuring that a number of medical laboratory scientists are currently in training outside Nigeria on the use of the recently developed corona virus diagnostic testing device.

But above and beyond the dread of Corona virus, Nigerians, especially citizens in Benue State now live in fear of what has been dubbed ‘the outbreak of a mysterious disease;’ a strange epidemic which its aetiologic agents are yet to be unravelled and hence considered idiopathic. At the last count, in less than one week, the disease left 15 people dead and dozens infected.

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With these and many other problems in the Nigerian health system, citizens are becoming increasingly worried that much is not being done to revamp and revitalise the Nigerian health system, particularly towards safeguarding the health of Nigerians from preventable diseases. It was not a surprise therefore that the renowned human rights lawyer, Chief Femi Falana, not long ago, described Nigerian hospitals as ‘mortuaries under the Buhari administration’.

Though the failure to tackle particularly Lassa fever headlong is, to some extent, due to want of political will by the federal and state governments, the rot and deterioration in our hospitals cannot be blamed squarely on President Muhammadu Buhari; physicians who are the managers of the system are to blame.

By sheer privilege of service as CMDs and MDs, physicians have turned themselves into hegemonic managers and administrators of our hospitals and health system, and they are responsible for the diminished in-country capacity of medical laboratories in the detection, diagnosis, and real time Infectious Diseases Surveillance and Reportage.

With physicians only occupying virtually every of its key positions, the Federal Ministry of Health have blatantly refused to enforce the necessary regulations, policies, and schemes which it itself created or have the mandate to implement in the public interest. For instance, medical laboratories in Teaching Hospitals and Federal Medical Centres exist without any form of accreditation.

What is the answer to the question as to why, today, over 30,000 primary health centres, PHCs, in the country are without medical laboratory facilities and personnel. Why is medical laboratory testing services not incorporated in the revised minimum health package as provided by the National Health Act? The non-provision of PHCs with facilities for medical laboratory investigations affirms why the PHCs have remained largely dormant, dysfunctional and at best, purveyors of poly-pharmacy.

This unfortunate situation in our public hospitals and its attendant negative consequences derives from the force of the obnoxious Decree No 10 of 1985 (Act CAP U15 LFN, 2004). The provisions of the law are archaic; it created the numerous lacuna that invariably offers manipulative advantages to doctors who are wont to embrace global best practices for effective and efficient health care services delivery to the benefit of the Nigerian people. That decree is the basis for the flagrant disrespect for other extant laws, abrogation of circulars, and health policies by doctors; and, if the decree is not amended, the leviathan physician hegemony will eventually destroy completely the Nigerian health system.

Clearly, the system requires urgent reforms which must be comprehensive. In particular, the reforms must unbundle the present hegemonic structure of the system into administrative, clinical governance and leadership structures, in order to calibrate the system to conform to global best practices. A situation where the doctor is the administrator, the racketeer of recruitment, the procurement officer, and at the same time the maintenance officer, etcetera, is inappropriate and remains the bane of the Nigerian health system.

A nation’s health system is only as strong as its medical laboratory system. With the sustained efforts at destroying the medical laboratory services and the practice in Nigeria by CMDs and MDs of teaching hospitals and federal medical centres, who leverage the active support of the Federal Ministry of Health, our health system, and especially the prevalence of preventable epidemics, will continue.

In order to strengthen planning and coordination of diagnostic, surveillance capacity, towards achieving a viral national health system, President Buhari must call for the immediate implementation of the priority action steps recommended by the International Conference on Global Health Security held in 2019 in Nigeria. Furthermore, the Federal Government must prioritise the establishment and development of a sustainable national medical laboratory system at the three tiers of the public health system. The time to reverse these retrogressive trends is now.

Dr. Ifeanyi is of the Association of Medical Laboratory Scientists of Nigeria