All Aboard…! Steering Nigeria’s COVID-19 Action Train

BY FOLA ADEOLA

The first case of COVID-19 was confirmed in Nigeria on the 27th of February 2020. Just a little over two months ago and, yet, it feels like a lifetime has elapsed. The world we lived in then, is so much different from the one we are about to be released into, as the lockdown restrictions are lifted. When the lockdown was announced by President Muhammadu Buhari on the 27th of March, there were 65 confirmed cases in the country and the President’s Chief of Staff had just tested positive for the virus. Today, we have confirmed over 2000 cases, and many of our beloved fellow citizens (more than 50)are no longer with us, having fallen in the wake of this novel coronavirus. May the souls of the departed rest in peace, and to those of us who remain on the journey of life, may God grant wisdom. We need it, desperately, at this time to navigate the complexities ahead.

The month we spent sheltering in place was, without question, challenging;but in our isolation there was an odd sort of togetherness, a shared helplessness with the rest of the world. Literally, everybody was hunkered down, numbering their afflicted, and counting their dead. The world went from an insignificant number ofconfirmed cases and an even more insignificantnumber of COVID-19 deaths on March 27th, to about three and a half million afflicted, and about a quarter of a million deathsas at last count. Some countries have had it worse than others. With the US recording over 60,000 deaths, and Italy, Spain and theUK each recording between 25,000 and 30,000 deaths, our own fifty-something fallen, in a population of almost 200 million, barely registers on the Richter scale of devastation in which the world has become engulfed. But it is not a competition. God knows we are not equipped to deal with what the countries of the West are going through.

The sojourn ahead, the path to a “new normal” on the COVID Action Train that each country has been forced to navigate will be less unified, more particular to each nation’s circumstances and challenges than the shared humanity of sickness and loss. Each nation is tasked withthe burden of its re-emergence. so let us turn our minds to our own COVID Action Train journey.

Perhaps a good departure point for us is a review of where we are, as a precursor to where we ought to be headed. When we began this journey in March, we had barely any infrastructure in place for the containment of this virus. But, somehow, with the borders closed and the elite locked in, nobody needed to tell Nigeria’s affluent that the country’s first line of defense rested with them. The private sector – corporations, foundations, and individuals – took the lead. Within a few weeks, isolation centers, ICUs and treatment centers had sprung up in different parts of the country – particularly in Lagos. Over 30 Billion Naira was donated, and additional in-kind contributions of food and healthcare products were and continue to be made. These donations made it possible for government, at the national and subnational levels, to make available cash stipends and “survival packs” to the more vulnerable populations in locked-down states.

Everyday citizens, also, extended themselves to feed the disadvantaged in their neighborhoods, and displayed basic human charity. Setting aside some of the controversy around the quantum and efficiency of palliative relief, and the self-protection inherent in some of the charitable giving, it is impossible to deny that Nigerians stepped up. Even those with a penchant for looking gift horses in the mouth, must stop to at least acknowledgethat this one time, with the fates of the rich and the poor “locked in,” Nigerians, particularly the elite, demonstrated a capacity to think beyond themselves that must – even for the most cynical of us – offer hope, at a time of such global devastation, that when push comes to shove, we will do for ourselves and one another. That maybe, just maybe, our self-loathing is not so entire as to obscure our collective desire to triumph over disease and death. That maybe, just maybe, the candle of enlightened self interest may have embered,and maybe, just maybe, it can be fanned into a flame that will light our path out of the valley of the shadow of COVID-19.

Perhaps…

It is probably also worthwhile to examine our COVID statistics and acknowledge a few things. Neither our confirmed cases, nor the number of recorded deaths is particularly high;not yet. And to those who would argue that the numbers are inaccurate, and cannot form the basis of sound decision making, I can only say that while that is true, the same is probably true of most countries around the world. We have not tested enough. I agree. I am, however, strongly of the view that we cannot and will not, for the foreseeable future, be able to afford the level of universal testing that would give us tangible path-lighting information.
There are, however, more basic indicators, even if imprecise, that we can examine. Our hospitals are not yet overburdened, our emergency COVID-19centers are not at full capacity, our morgues are not spilling over, we are not modifying refrigerated containers to hold the dead, and we are not constrained to dig mass graves. The imagery is stark, and I apologize to those whose sensibilities may still be penetrable, despite these past few weeks of CNN onslaught. This is the unfortunate reality of many of the countries of the West, who, before this pandemic, would have had their healthcare systems described as robust.

Our very fortunate position is not the triumph of preparedness on our part for COVID-19, and it is important that we not deceive ourselves. It is the absence of an onslaught. Those who choose to hide their affliction, as if an airborne disease should be a source of shame, by checking into uncertified private hospitals, can still do so because the hospitals are not overwhelmed; and those who scowl at the rich for carrying on like spoiled brats and choosing self-care over dedicated public health infrastructure do so because the IDH still has beds that we would like to see the rich occupy. We do not have pandemic-level infection rates in Nigeria. If we did, we would curse the rich for daring to monopolise the few beds that would offer ordinary people a chance at survival. Our infection rates are not high;not yet.

This is not to say, that efforts are not being made to get at least some idea of the numbers of infected people, outside of those who have self-reported or presented with symptoms. Let us not sell our public health officials short. Lagos State has, since mid March, focused on expanding the testing dragnet to include contact tracing, and randomized sample testing in the various local governments. The same is true in Edo, Ogun, FCT and Kaduna. The results from these efforts will give us some sense, if we extrapolate, of the likely transmission and infection rates of the virus. Will it ever be enough to develop accurate projections? No, it will not.

But let’s not get carried away by the global clamour for testing. In the here and now, the resources don’t exist for universal testing in Nigeria, or indeed anywhere. There aren’t enough tests in the world, and they cannot be produced quickly enough. Even if they were available, all the cash donations of the elite and corporates put together would not cover the cost of universal testing here. What we can do, rather than fantasize, is examine the stats that we do have, and track other moderate to severe disease indicators like symptomatic presentation at primary care centres, hospitalisations and deaths – even if they are lagging indicators – that do not lend themselves as easily to obfuscation, and reach an educated conclusion. We do not have a pandemic, yet.

I emphatically use the word “yet” to qualify our COVID-19 situation, and have probably done so enough times in the course of this write-up to beg the question: “This man, are you praying for Corona to come?” It cannot, after all, be a coincidence that this lockdown occurred at the cusp of the Christian Lenten period, and the Holy Month of Ramadan. Yes. As a praying person myself, I need no convincing of the power and mercy of God in the affairs of men. I am, however, unconvinced that we are the only ones who pray, or that in this one thing, God is partial to Nigeria and Nigerians because the committed Christians and faithful Muslims in the rest of the world are somehow less worthy than we are. If God shows us mercy, and we never experience a full COVID-19 pandemic in Nigeria, let it be because when the window to act was given to us – which others may not have had, mainly because of the virus’s migration pattern – we chose to act wisely, and use the information we have today that others did not at this stage in their own journey to alter the course of its trajectory in our nation.

It is probably useful that we also examine another important aspect of our COVID-19 profile. When I describe us as not yet having a pandemic, it is important that we not read that to mean the expectation of a “second wave”.Frankly, that is much further ahead of where we are than any of us can venture to posit on. The number of cases, while low, has neither peaked nor begun to decline in Nigeria. We are, to be clear, easing the lockdown while still on the ascending end of the curve, much earlier in the course of the disease’s trajectory than the countries of the West. We can take this calculated risk because our numbers are low relative to population size, and frankly because we must strike that delicate balance between lives and livelihoods. We cannot afford to stay closed longer, so we have taken the upfront pain of a month-long clamp down, in the hope that this initial containment will improve our chances of long-term management. That is the strategy. We have not peaked, we have not plateaued. Our numbers remain on the rise. The first wave is still on course but our numbers are sufficiently low to enable a cautious restarting of our economy to ensure survival. Already, we are dealing with a collapse in oil prices. Most of our people inhabit a daily economy. Continued closure may not be an option.

As we prepare to continue our COVID-19 Action train journey, we must consider what we know about this virus, and the possible alternatives ahead of us. It is possible that the infection rate in Nigeria will remain manageably low; because our tropical climate may be a deterrent, or/and because those of us in the developing world have more active immune systems and are less likely to develop severe disease, or/and because we are successful in adapting to a “new normal”.

It is also possible that we will experience an aggressive steepening of the curve, because we are not special, or/and because that is the likely outcome if we fail to adapt to an enemy that is already within, or/and because this virus has a continental sweep pattern, will travel when we eventually open up our borders, and be carried along or arrested by whatever behaviors we begin to implement now. Even with heat, and without migration, this virus has shown that it will spread here. So, we must continue on this journey knowing that thisrelatively “managed” situation of ours can, spiral out of control very quickly, given our lean resources, if we do not make significant changes as we ease the lockdown. We have been able to slow the spread thus far, but as we begin to move around again, those who have been exposed to the new cases we are recording today, will also start to move about and shed the virus in their droplets – as they speak, cough, sneeze and touch surfaces and currency notes everywhere they go. This is not a prediction of doom; it is an acknowledgement of science, and the realities of how this virus has behaved even on our own shores.

Are we prepared to play the game of odds with nearly 200 million lives at close quarters?

Another thing to bear in mind, is that in the absence of a treatment or vaccine, COVID-19 will remain with us across the globe for the foreseeable future. Even the best-case-scenarios for vaccines and treatments put us at least a year to 18 months away. Having a formulation that works is one thing. As we have seen with testing, making enough of it to cover the world is another. We are probably some 2 to 5 years away from being able to treat this virus universally.This is a best-case scenario. This virus is not going away any time soon. It may travel in waves, peak and trough, but in the absence of a vaccine, the outbreaks are here to stay. Quite possibly, by the time a vaccine reaches us, herd immunity will likely have set in. After all, we know that about 60 %to 70% of people who become infected will have mild or no symptoms. That even of those who develop moderate to severe disease, 65% to 75%will live.

COVID-19 is not a death sentence, but it spreads easily and rapidly, and disease progression in the vulnerable, moves with a speed that makes the simultaneous treatment of many patients, literally a losing race against time. So the better we get at reducing the number of people who are infected at any one time, the more likely we are to be able to reduce the number of deaths in Nigeria; and the more likely we are to benefit from the greater body of knowledge and treatment protocols that are being developed worldwide. We now know, for example, that the ventilators should be a last resort, as only approximately 20% of people who are put on them will likely make it off. Slowing down the spread also improves our chances of access to drugs. The more we are able to reduce the number of people with severe disease, the more likely we are to have enough medication to go round.

As we transition from fully sheltering-in place to restricted interstate travel and reduced intrastate movement, my purpose in writing this article is to warn, like the town criers of old, that our next stop on the COVID-19 Action Train must be Redesign, not an express ride to Self-Congratulation. This is not over, not by any means! And we cannot allow ourselves to be lulled into a false and dangerous belief that post-lockdown means post-COVID-19. This is the time for all of us – leaders in the public and private sector, private citizens, parents, educators, all thinking and sufficiently educated people – to consider the information we have available about this virus, its behavior and management, and prepare as much as we can for the altered reality ahead of us. Our ONLY chance is to actively change the ways in which we live and work, to reduce the spread of this disease. The rest of the world has its hands full; nobody is leaving their own country to come and save us.

I had written early last year about the 12 Giant Evils that plague our country. In COVID-19, a powerful cocktail of those – Disease, Squalor, Want and Ignorance – is what we are up against. Itwill likely proliferate the already-present evil of Idleness,and spill over into every aspect of our lives, if those who are, by fortune, not already Nigeria’s victims, do not act NOW to bridge the gap. Just as the private sector and private individuals acted swiftly to ensure that emergency facilities were putup, we must continue to act jointly and decisively – hand in hand with government (ahead of government, even) and with one another – to steer our COVID-19 Action train to a desirable destination.

I have heard manytalk about hoping/praying for the best, and preparing for the worst. We need to go further,and take proactive and extraordinary steps toRedesign our lives and economy for the best because, honestly, the worst will decimate Nigeria. We must do what we can to avert it; it simply cannot be planned for.
We must review the facilities and supplies we have acquired thus far,and start to move from emergency interventions to sustainable ones. We ought to apply the monies received from the EU, and IMF for COVID-19 interventions, to implementing a near to medium term healthcare overhaul. Temporary structures need to give way to permanent treatment facilities, with protocols that can be stepped up or down depending on what disease we are managing. Reinventing the wheel is unnecessary; we can start with re-tooling the teaching hospitals. We need to purchase equipment – ventilators are the most talked about -but we also need life support systems, telemedicine facilities to facilitate knowledge sharing. We live in the tropics. COVID-19 or not, we need more infectious disease treatment capabilities.

We must not take our eyes off lassa fever, cholera, and the other diseases that were with us before COVID-19 came along, because they have not gone away. We need to train and adequately incentivise our health workers, and we need to bring a level of health awareness to our population. All of these things can be fast-tracked, not by building new white elephant healthcare projects, but by judiciously applying our limited resources to making whole the abandoned or incomplete facilities located in high-density areas where they will be utilized, COVID-19 or not. We can continue to upgrade the knowledge of hospital staff, and teach them to recognize disease presentation. We can inject funding into the pharmaceutical and medical equipment industries and start to produce more frequently used drugs/items locally. God knows, we need the jobs,
Beyond healthcare infrastructure and supplies, we need to ensure that we are able to prioritise steady power to hospitals and these healthcare manufacturers, particularly during healthcare crises. We must have state and national health emergency protocols and triggers. We must plan for the possibility of another, maybe more than one, lockdown. We must keep the conversation with citizens going, so that they are carried along and cooperative, if we need to return to sheltering in place down the line. We must let them know that their behaviour as we return to daytime activity will determine whether or not we can continue to service the economy, and live. We must learn lessons from this first firedrill and avert, not prepare for worse.

Ideally, we should have a healthcare reform budget and implementation tracker, alongside our COVID-19 tracker – in plain sight, for all to see. It would be best if we could account for funds received and utilized sums, openly and transparently. It would be great if the public could see in real time, what the designated projects are, and cheer along as they are completed. It would be good if the private sector can see what can be done to bridge funding gaps through cash and in-kind donations. We are told that the funds received in the first round of COVID -19donations will be eligible for tax credits. It would be good if a Healthcare Infrastructure and Refurbishment Investment Tax Credit Scheme could be considered, as an extension of this. But let’s not let the best become the enemy of the good. It would be sufficient if we started simply by upgrading a few of the teaching hospitals and taking over their uncompleted projects.

While Healthcare reform addressestreatment,prevention is better, and it is a communal responsibility. We must take what we know about how the disease spreads, and modify the way we live with and in spite of it. Communication campaigns, as fervent as those we see during elections, and as star-studded as the ones we have seen in the last few weeks,are required now for an even nobler purpose. We must help everyday people understand that each of us holds the other’s health in our hands. We have told employers that work can resume, we must also provide clear industry guidelines on how that work should proceed. The guidelines must be practical and pragmatic. They cannot crush the cost structures of the businesses they are designed to protect, but they cannot be so discretionary, that business-owners’ short-cuts lead to workplace outbreaks. We have asked citizens to mask up, we must tell them the masks need to be washed daily, or risk the onslaught of other diseases. We will eventually ask children to return to school; how will we manage disease spread in already crowded classrooms. Masks are uncomfortable, how do we get children to keep them on? What will we do about our dirty cash problem, that was here long before COVID-19? What will our “merrymaking nation” lives look like without parties? How will we ensure that they don’t move indoors, go “underground,” and crowd homes rather than event centers?

We must also come to terms with some of the deeper implications of this “redesigned” life. Other than large corporates, most businesses cannot afford to pay staff when they are not earning money. Many will not survive. In some cases, the month-long shutdown has already sealed their fates, others will limp along for a little while longer. For traders, dependent on regular aviation traffic to receive goods, their supply chains, lead time, buying costs, everything, will shift. Others have business models that simply cannot survive a “mask and distance” or curfew regime – restaurants, bars, hotels. What will happen to them? What happens to our event centers: will they be re-purposed and converted to other uses? What about the entire economy that is built around our merry-making: catering, cakes, clothing, makeup, musicians, photography, money-changers, parking “attendants”, what adjustments will they need to make? Are these restrictions here to stay? We must assume that they are, and prepare our people for significant disruptions and adjustments. Because human behavior is elastic, the first hurdle ahead will be getting people to recognize and heed the need to shift. We can expect that people will first attempt to return to the status quo ante, or some variant thereof, and only retreat if they are unsuccessful or suffer harm.

We can shrug; afterall, the problems will touch everyone. Why should some of us take Panadol for everybody’s headache? The answer is “because we can”. Because we can put these newly unemployed people to work in a redesigned economy. Because we can invest in local production, and decrease our dependency on imports. Because we can do the unfashionable thing and finally shut our doors to anything but progress, without looking like fascists. Because we can find and weave together the silver linings in this haze of dark clouds into the fabric of a new society. Because we can ride the COVID Action Train to a different, better Nigeria. Because portfolio investors parading as FDI will flee, but if we, the owners of the economy, do the right things now, a path can be created towards welcoming real growth capital when the world is restored. And, frankly, because the alternative will engulf us all. Because if working parents lose their livelihoods, children will be pulled out of school, and ignorance will increase.

Because this delicate balance of lives vs. livelihoods can only be managed if those who can join hands to create safe livelihoods for those whose ability to eek out an existence must be sacrificed for us all to live. Because hungry people will eventually take to the streets (the threat of this was palpable over the course of this lockdown), when opportunities to make an honest living suddenly disappeared. And because, in the new “balaclava nation” that we will occupy when we all “mask up,” faces will be obscured and only eyes – desperate eyes – will be last thing we see before the curtains fall. God forbid we let it come to that.

•Fola Adeola, OFR; mni. Chairman, FATE Foundation Coordinator, FATE Philanthropy Coalition for COVID-19.