INTERVIEW: Why Nigerian health workers are vulnerable during disease outbreaks – Health Minister

Isaac Folorunso Adewole is a Nigerian professor of gynaecology and obstetrics. Since November 2015, he has been the Minister of Health in the cabinet of President Muhammadu Buhari. He is a former vice chancellor of the University of Ibadan and President of the African Organisation for Research and Training in Cancer.

In this interview with PREMIUM TIMES’ Ebuka Onyeji and Ayodamola Owoseye, Mr. Adewole speaks on outbreak of Lassa fever among other diseases, routine immunisation and other challenges facing the Nigerian health sector.

Excerpts….

PT: Why is it that health workers easily get infected during disease outbreaks, especially Lassa fever?

Adewole: The simple analogy is ‘why do soldiers always die during battle?’ It’s because they are the ones in the war front. In this context, the doctors and the health workers are the generals and the front line soldiers and they are fighting a war, and that war is against diseases. So it’s one of the hazards. So the question is on how we minimise it. Soldiers wear bullet-proof vests to avoid complications, they wear full amour kits to protect themselves from unexpected fatality. We are also keen on protecting our own front line soldiers and generals. The problem is that some of the patients will not tell us the truth. You know what happened to Patrick Sua? He lost his relation to Ebola, yet when he got to the hospital in Lagos, he denied and the people didn’t know. We have many cases like that where patients come in and say ‘no, I am fine’ and all that; they will say the fever started yesterday when in fact it started two weeks ago. So, there is problem.

Another problem is that by virtue of our profession, we tend to show compassion by always getting closer to patients, hence the risk.

PT: Since the first case of Lassa fever was recorded in Borno State almost 50 years ago, it seems there has been an increase in cases and spread of the disease. Why is this so?

Adewole: We have had Lassa fever for over 50 years, but what happened in the last two to three years is that we put in place measures to be able to pick cases whereever they occur. We have surveillance officers across the country. So what we are saying is even if you have one case, let us know so we can determine if its presumptive, possible or confirmed case. It’s not every presumptive case that is Lassa fever, but we are creating a situation where everybody will think Lassa.

The Nigerian Centre for Disease Control (NCDC) has become more proactive. Of recent, WHO gave us 853 motorbikes that will enable us to reach every corner of this country. So if you could recollect in 2015, we lost 73 people in one village in Niger State even before we got to know; that will never happen again because of increased awareness. But we’ve had bigger bumps in the past. I think we’ve recorded bigger fatalities in the past, but what we are trying to do is to work with other ministries. When the environment is filthy, you are sending invitation to Lassa fever. But we also know that the peak period is the dry season. The rat and other agents that transmit these diseases, they are hungry inside the bushes and they move nearer homes and they urinate on our food and other products, especially if they are contaminated. So this is the peak period. What frightens us mostly is the fatalities, we don’t want anybody to die from Lassa fever because it is treatable and preventable.

Also, we would want health workers to think Lassa; because when they can easily get infected, anybody that will go to them for treatment is at risk.

PT: Why are some of the virology centres built not functional; yet to detect most of these outbreaks?

Adewole: I am not aware of some of the virology centres set up. I am aware of a centre donated by Ebonyi State government, but after the donation, the governor said the federal government should reimburse him about N420 million; and of course we cannot do that.

The problem has to do with how do we operationalise? We have a plan to operationalise one zonal centre in each area and it’s ongoing, we just finished with the national one. Before, there used to be a public health laboratory in each state, but they all collapsed, so we are trying to put life into all of these. We can’t do it all at a go, we’ve started national and when they are fully functional, we now set up the regional ones. We are quite committed to this.

PT: Is the regional going to be in collaboration with NCDC?

Adewole: It’s not in collaboration, it’s the NCDC that will manage it. NCDC is a parastatal of the Federal Ministry of Health. So we speak the same language.

PT: We are asking because at the public hearing on Lassa fever, it was said that six centres will be established in the six geo-political zones of Nigeria?

Adewole: That’s what we are doing. I was at the public hearing.

PT: So how do you expect the centres to function, what should we be looking out for?

Adewole: We have started at the national level. The national reference lab that has been in coma for many years is now functional. We have put it in good shape. We are hoping that President Muhammadu Buhari will commission it anytime from now. It’s ready. We don’t have to take samples again to Dakar or any other place.

PT: Which is more preferable for Lassa treatment – oral drugs or injections?

Adewole: There are two types of drugs. A tablet and injection. I will rather take tablets than injections. We are even discouraging injections generally. For malaria, we are saying no to injection. We only give injection when the patient is terrible and can no longer swallow. The NCDC produced a guideline for management.

PT: Some health workers are complaining of poor communication and poor campaign by the federal government in the fight against Lassa.

Adewole: It is wrong to blame the federal government. Health is on the concurrent list. The state government should also look out for people in their states. One of my MDs (medical directors) came and said he wants to buy a bus for the state he was posted; I said that’s not your job. It’s the job of the state government. If somebody has headache in Sokoto or Ibadan, it’s not my job to treat them. The local governments, state and federal should work together.

It’s easy to destroy than to rebuild. There was a time each hospital had an isolation ward, where is it now? Either collapsed or destroyed. We are now asking each of our teaching hospitals to have an isolation ward because we don’t want everybody with Lassa to go to Irua Specialist in Edo State, which is in forefront of teaching other centres.

People critically ill often die on the road when they are being transported over 500km even before getting to Irua.

PT: Is there any progress towards getting vaccine for Lassa fever?

Adewole: There are improved trials which are yet to be tested and we want to be a part of these trials. The pipeline is a bit long. It will take years. It will go through animal experiment, it is now safe to be tried on humans.

PT: What is government doing to curb the spread of Lassa and other outbreaks?

Adewole: Since last year, we developed videos which we sent to all the states. With these videos, we want each state to educate the people. It’s an ongoing exercise, we need public awareness. This is not the time to stay at home and be doing self-medication.

PT: What is the coverage rate of immunisation in the country?

Adewole: Previous governments said it was 80 per cent, but this government came out with the truth. We did a nationwide survey and said it is 33 per cent, which is ok. Some of our international partners thought we won’t release the figures, but we did. We are not afraid to tell the truth. What will be a shame to us is if over the next couple of years there is no improvement. The target is 80 per cent by 2022. We will gradually work towards that.

PT: Despite several efforts, Nigeria is the only country in Africa yet to be declared polio-free. How does that make you feel? What are the plans towards a polio-free nation come 2019?

Adewole: We are almost there. We would have been there by 2017, if not for the cases in 2016. With those cases, things are now tighter, we are not going to declare ourselves polio-free easily until security challenges in some parts of North East is addressed, because we have two LGAs we have not completely covered in Borno, and until we do that, we are not going to declare Nigeria free. I think as of the time we said we were polio-free, what we did was wrong. We should have declared that part of Nigeria that was accessible free of polio, that’s scientific. But we said we were polio-free, forgetting there are two LGAs in Borno that we cannot gain access to and that’s where we picked those four cases. We are working with the military. We have a programme called reaching the inaccessible children in those LGAs, and over the last two years, we’ve vaccinated over 200,000 children in that enclave. So as we move forward, we are also working with some Lake Chad countries like Chad, Niger, Cameroon, among others. We want to address this issue once because if we are free, then the whole of Africa is free.

PT: Why is the National Health Act yet to be implemented?

Adewole: That’s wrong, it was passed into law, signed in 2014, gazetted and released early in 2016. Every part of the Act has been implemented, apart from the Basic Health Care Provision Fund. And on our own, we are doing a pilot project and that pilot project will entail offering health care to eight million Nigerians in three states in the next few months. In our budget, we also put some money as part of the pilot project. We don’t want to cover the whole country at a go, but we can start gradually and learn from that.

The Act enables and empowers the minister to determine what the basic health care packages should be and I have done that. All the committees we have formed such as the National Council on Health is meeting. When you say we have not implemented the Act, then I think you need to read the Act; then you will give us credit because we have implemented it almost fully.

The media should be helpful in disseminating these information. Under this administration, the National Council on Health met four times. Including two emergencies. We had an emergency meeting on Lassa fever. In terms of working with the commissioners, we are there. In terms of National Health Policy, we are there. Yesterday (January 30), I received notification of an approval for us to do a nationwide survey on HIV. So if there is one tiny bit of the Act that is yet to be implemented, you can’t say we’ve not implemented the Act or that it’s not working. People should be more categorical. There is one Yoruba proverb that says that the calabash is heavier than the plate but what the person was referring to is a cold or wet calabash, because the dry one is not heavy.

PT: The yellow fever vaccine campaign is on, will the FG be giving out a yellow card? If you are vaccinated and you are given the card, how long does it cover or make you immune?

Adewole: The vaccine will cover you for at least 10 years, minimum if you are vaccinated. Some say it’s for life, but 10 years is quite enough. We have not covered Nigeria as a country for long, so we are doing a nationwide campaign that will last about seven years and it will last this long because the vaccines are not easily available. But we are talking to GAVI and they promised more supply. We have received 25 million doses.

PT: What is your take on the 2018 budget, which size in percentage term of the total budget is far below the Abuja Declaration?

Adewole: To me, the Abuja Declaration is a statement of intent. I would love to have the entire national budget for health, but I must also be realistic. As a minster, I am part of the team. Of what use is the entire budget for me if there is no water and electricity, if the roads are not done, if people are not educated? What will gladden my heart is a gradual increase until we get there, and I am quite happy that we are moving in that direction. Though the funds are not enough, even the entire budget won’t be enough for me. If I have enough money, I will vaccinate everybody against meningitis, yellow fever and I will declare free health, but I must be realistic.

PT: Why are there so many abandoned Primary Health care projects all over the country?

Adewole: When you say PHC projects, are you talking about federal? Because PHC is not under us, it’s under LGAs. Why we made PHC a focus is because we just have to take care of it. But normally, PHC is not the responsibility of the FG.

PT: But the FG said early last year that it will revitalise 10,000 PHCs …?

Adewole: It’s not FG that is revitalising, what we said is that we want to see 10,000 PHCs revitalised in Nigeria. Because if 10,000 is done, it will cover about 100 million people and we did this to stimulate the governors and many of them have taken it up. At the last count, Niger has done 40. We did three in Niger and we call them model PHCs, so they can follow cue. The president commissioned one in Kuchingoro. In Kaduna, the governor has done 255. I’ve commissioned in Kebbi, Abia and other states. What we are asking the governors to do is to invest and we partner with them. I can also tell you as of today, the World Bank has done about 1,500 PHCs. The EU is committed to 774. The British government is doing 950. FG was committed to 110 last year. This year, we will do more. So over all, we are adding them together and we will now ask the states how many they’ve done, where are they located? We are also doing an inventory of the PHCs done by ALGON.

We are also appealing to the National Assembly not to create more PHCs, because having a building is not synonymous to a health centre. A building without human resources, equipment and drugs is not a health facility. Everybody wants to build a PHC in his village, but who will run it? So we are begging them to stop creating.

PT: We know that PHCs are under local governments. Bearing in mind that local government’s are the least in terms of resources, how do we expect them to manage these PHCs effectively in terms of getting staff and basic amenities needed?

Adewole: That’s why we are talking about ownership. We want the people to own it. There is a model in Ibadan where a committed man donated a building to people in Ward 3, Ibadan North LGA for a model PHC, And at the ward, it is jointly managed by his foundation, the people in the ward, as of the last count, have registered about 18,000 clients and have N20 million in their account. The beauty is that they mapped out the entire ward to know who is who, so that if in a household they are having many cases of fever, they can easily know. So many of the model PHCs can survive on their own in that manner. What we are doing beyond that is that we are implementing the Basic Health Care Commission. Money will go down directly from CBN to the facilities, so that they can survive. It is that funding that is lacking, but once we can do this, many will survive. The model we are building in Nasarawa State will have two signatories to the account; a community leader and the head of the facility, so they can manage it and it becomes theirs, because when you say it belongs to the government, it doesn’t work that way.

PT: What’s your take on doctors working in public hospitals that are owning private hospitals?

Adewole: The Vice President, Yemi Osinbajo, while in acting capacity as the president, received petition about doctors running private practise and it came up as part of the committee report. The government then set up a committee to look into the abuse of public practise by doctors who own private hospitals. So whether it will be banned after that depends on what is submitted. So we are looking into the abuse. Certainly, we would not want a situation where people will not be at work when they ought to be there or they should resume in the morning but you cannot find them because they are in their private hospitals. To me that’s an abuse and we are looking into it.