From where it was first reported in Wuhan in the People’s Republic of China in December 2019, the pandemic of the SARS-CoV-2, or Coronavirus-2019 (COVID-19), caught the entire global community unawares, inflicting a deadly blow on the global economy. It has also impeded human migration and mobility, altered politics in various jurisdictions and shattered the normative structures of international relations. The inadequacies in global health systems have been exposed through the pandemic as the virus overwhelmed celebrated health systems in the global North, with a huge number of deaths. Creating fear among the rich and unsparing of the poor, COVID-19 has infected more than 3million people globally and it is said to have been responsible for more than 200,000 deaths.
As at 29 April, 2020, Nigeria had 1,728 confirmed cases, 307 recoveries, and 51 deaths spread across 34 states and the Federal Capital Territory (FCT). With COVID-19 in Africa, and Nigeria in particular, the apprehension of many has been about how the frail health systems would respond to this major health emergency.
To contain the spread, Nigeria’s federal government placed Lagos and Ogun States, and the FCT on total lockdown for over one month, with the attendant socio-economic consequences on livelihoods, health and other forms of insecurity. Although there is hope that this lockdown will be phased out in those states from May 4, 2020, the evidence of community spread of the virus poses a new challenge which policy makers and COVID-19 task forces at the state and federal levels need to examine closely. This is particularly challenging, given the health and crowded situation in urban slum communities.
In this piece, we share the results of the stakeholder engagement undertaken by the University of Ibadan Urban Health Research Team consisting of Prof Akinyinka Omigbodun, Prof Eme Owoaje, Dr Funke Fayehun, Dr Olalekan Taiwo, Dr Doyin Odubanjo and Dr Motunrayo Ajisola. This research on improving health status in slums was commissioned by the UK National Institute for Health Research (NIHR) using Official Development Assistance (ODA) funding. We engaged stakeholders in the slum communities of Bariga, Idi-Ikan, and Ṣáṣá communities in order to gain insight into their awareness of the virus, coverage of slum communities by government’s COVID-19 task force teams and what ought to be done to bridge the gaps and limit the spread of COVID-19 at the research sites.
Understanding these issues will assist the governments to make evidence-informed policy interventions to tame the spread of the virus in the urban slums of Lagos and Oyo States. The findings indicated poor adherence to social distancing and scarcity of facemasks, while health care providers lacked essential protective kits.
Bariga, Idi-Ikan, and Ṣáṣá slum communities present different scenarios in relation to how they are affected by coronavirus. While Bariga is in Lagos and has been under a total lockdown for more than one month, Idi-Ikan and Ṣáṣá in Oyo State are only partially locked-down which affords residents to move about during daylight hours.
However, all sites suffer similar neglect in terms of access to quality healthcare. Bariga has 1934 households with 14 health centers while Idi-Ikan has 1617 households and 36 health facilities. Ṣáṣá has 1755 households with 32 health facilities, consisting of one public primary health centre, one maternity home, two private clinics, five herbal and spiritual centres, one optical centre and 23 patent medicine stores. The preponderance of patent medicine stores as places where residents seek healthcare is also the case with Idi-Ikan and Bariga. This implies that there is a limited number of qualified health personnel to guide and advise slum dwellers on the best approach to safeguard their health.
While residents in the three slum communities initially adhered to movement restriction orders, they could not continue to stay indoors after about ten days owing to deteriorating socio-economic circumstances. As a fishing community, fishing households in Bariga survive with fish sales but other artisans and their households were badly hit by the loss of their daily earnings. While money is scarce, available goods have become more expensive. The housing situation in the slums leads to poor observance of social distancing in the communities. While some increased the frequency of hand-washing in their homes, scarcity of water prevented the majority from observing this preventive measure. Bariga residents complained of the scarcity of facemasks and hand gloves, which meant that the few that were available were too expensive for them to purchase. Adopting a rational choice approach to life decisions, they used available money to buy food rather than buying facemasks or sanitizers. Palliative intervention came from non-governmental organisations but this was grossly inadequate for these vulnerable populations.
COVID-19 has reduced the number of patients who approach health centres for care in the slum communities. This is partly due to the fear of contracting coronavirus in the health facilities following news that some frontline health workers had become infected while treating patients. Many people who became ill did not have sufficient money to pay for health services. According to health care professionals in these communities, sick patients only came when the illness had become severe. The danger is that this new attitude may facilitate community transmission should any of the patients become infected with COVID-19 and refuse to present it for care.
Health care professionals in Bariga, Idi-Ikan, and Ṣáṣá primary health care centres reported different interventions from their state governments which has had an impact on their service delivery. While Lagos State had organised preparedness programmes on COVID-19 for health sector workers, this was yet to be implemented in Oyo State. In all three sites, health workers complained of insufficient numbers of personal protective equipment (PPE) to shield them from infection. Consequently, they had stopped organizing health talks in Ibadan slum communities while Bariga had paused labour and delivery services because they could not provide 24-hour services. Worse still, stigma may make it more difficult to screen for COVID-19 in slum communities. Patients referred to COVID-19 test and isolation centres were reluctant to go due to the social implications. There is, as yet, no COVID-19 testing centre in any of these slum communities in spite of their large population and high level of mobility.
The results of the stakeholder-engagement have unveiled some of the gaps in the current fight against COVID-19 in both states. There has been insufficient attention paid to urban slum communities and their access to health care utilisation. It is important that both Lagos and Oyo State governments consider alleviating the social and economic deprivation being experienced by the slum dwellers. This is likely to assist them to observe preventive measures against COVID-19. It is also dangerous not to protect health workers who will still have to attend to patients with other ailments. The decision of the Lagos State Government to pay enhanced hazard allowances to healthcare workers in the State is highly commendable and it is important that this is replicated in Oyo State and other parts of Nigeria. It is vital to distribute free face masks and hand sanitizers in urban slum communities to enable them adhere to the advisory notices being issued. Locating COVID-19 testing facilities in these urban slums will enhance early detection of the virus and limit community transmission in Lagos and Oyo States as well as other parts of Nigeria.
Professor Omigbodun is the principal investigator of the project in Nigeria