The Verbal Autopsies from Kano By Olusegun Adeniyi

If there is any lesson we have learnt from the past five weeks, it is how difficult it is to enforce a meaningful lockdown or social distancing in Nigeria. All over the country, wherever restrictions are imposed, the pushing and shoving that occurs during market hours have themselves become serious risk factors. Last Friday, two children were crushed to death in Taraba State following a stampede at Jalingo main market during the four hours (10am to 2pm) allotted for residents to stock household essentials. Many churches and mosques continue to remain open. And last week Monday, thousands of young boys in Kano took part in a football tournament described as ‘Corona Cup’. Despite Abia being “the only state that is mentioned in the Bible” which resulted in Governor Okezie Ikpeazu’s promise that “none of these diseases will touch God’s people” and that COVID-19 “will also pass us by,” two index cases have been recorded in the state. And by last night, the virus had been confirmed in no fewer than 33 of the 36 states and Abuja. I believe we can now safely conclude it is in every state of the country.

In one of my earlier interventions on the COVID-19 pandemic, I warned that a nation of our demographic magnitude must remain on perennial alert for potentially devastating public health emergencies. I also spoke to the hunger and deprivation that many would face in the event of a lockdown they neither anticipated nor prepared for in advance. When life is a struggle, according to The Economist article I referenced, “it is hard to worry about a threat you cannot see.” In a subsequent column titled, ‘Mallam Has Said There’s No Corona’, I admonished Nigerians to brace ourselves for the immediate, short, medium and long term implications of this global pandemic and its ensuing health, social, political and economic ramifications. Almost all my ‘prophecies’ have come to pass.

In managing COVID-19, my biggest concern has been that if governors were left to take uncoordinated actions that do not fit into a national strategy, the virus would enter their communities with all the dire implications for the health of our society. By not taking direct responsibility from the outset, the president allowed governors too much latitude in dealing with a global pandemic. One governor in the South-South is drawing huge crowds, propounding silly theories to his largely illiterate (and clearly endangered) audience. Others are closing ‘borders’ to their states and personally arresting citizens. While one governor in the South-East is legislating ‘Koboko treatment’ for any journalist in his state who would not report the pandemic the way he wants, some of his northern colleagues have been exchanging Almajiri deportees almost as if these neglected citizens were diplomats of their ‘states of origin’. Amid all these, majority of Nigerians are still waiting to ‘eyemark’ the palliatives on which billions of Naira are being earmarked by the federal government and the authorities in the states. But the biggest challenge has now come from Kano where people are dying in droves, with strong suspicions that the deceased may have succumbed to complications arising from COVID-19.

When on 30th March President Muhammadu Buhari declared a 14-day lockdown of Lagos and Ogun States as well as the Federal Capital Territory, I wondered whether he was well advised to leave out Kano. When, in renewing the 14-day lockout on 13th April, he again ignored the state where a monumental tragedy was developing, I was beyond shocked. By then, the first index case had been confirmed in a manner that should have sent alarm bells ringing. The patient, a retired diplomat, had attended the popular Da’awah Juma’at Mosque as well as two private hospitals and had mingled with several people within the city. The only major action taken in the aftermath was that “all commercial tricycle riders will carry only one passenger” and that the task force would “also meet with Chief Imams of Juma’at mosques and Reverend Fathers to decide on how to operate places of worships in order to curb the spread of the virus.” It therefore came as no surprise when within a period of 24 hours last Thursday, no fewer than 23 prominent citizens died in the city!

The signs of an implosion in Kano had been there since 21 March when Governor Abdullahi Ganduje inaugurated the COVID-19 Task Force with his deputy, Nasiru Yusuf and Professor Abdularazaq Garba Habib as co-chairmen. Habib, an expert in infectious diseases at the Bayero University, Kano, was expected to lead efforts. But a few days after inauguration, Habib tested positive for COVID-19 along with two other members of the task force. So, the structure established to fight the pandemic in the state collapsed before the assignment even started! That provided a perfect opportunity for Dr Amina Ganduje, daughter of the governor who had been appointed into the task force, to practically take charge. And from that period, efforts to tackle COVID-19 in an urban centre like Kano became a family affair.

Although he was initially in denial about the Kano deaths, Ganduje admitted for the first time on Sunday that there was a challenge: “I will like to inform you that the situation is getting tougher and tougher; the situation is getting serious, and serious and very serious. But equally the same, we are determined. They say when the journey is tough only the tough can keep on moving. We assure you we will keep on moving until we see to the end of this deadly disease with the help of Allah.” Ganduje can keep on ‘moving’ in whichever direction he likes but harassing the federal government for N15 billion will not address the monumental health crisis that has now been foisted on his state.

Having finally admitted that the number of deaths points to something unusual, the state has now resorted to ‘verbal autopsy’ to unravel what happened. “Kano State government has begun house-to-house engagement with families of those that have died to carefully administer questions on the symptoms exhibited by the victims before they died. This is what is termed clinically as verbal autopsy and it will allow the health professionals to predict the possible causes of the recorded deaths,” said COVID-19 task force deputy coordinator, Dr Sabitu Shu’aibu. That exactly is what I have also been doing in the past few days by speaking with many of my friends in Kano as well as prominent citizens within the city to unravel this ‘mystery’. Their feedback scares me.

Hours before the president declared a lockdown on the city on Monday, I received the report of three Kano-based female medical practitioners who conducted an investigation into the deaths. The trio of Maryam Nasir, Zainab Mahmoud and Khadija Rufai said that over the span of 48 hours, they received reports of 183 deaths in Kano metropolis that occurred between 18th to 25th April, 2020. Following a verbal autopsy they conducted, using the World Health Organization (WHO) template, they gathered two sets of data from the deaths. “The first data set was obtained through direct family members (first degree relatives) of the deceased and the second data set was from indirect sources (friends, neighbors or relatives of the deceased). We obtained demographics, symptoms, exposure history and medical history of the deceased. Some family members volunteered further information around the deaths. We compiled and analyzed the data,” they wrote in their report.

The conclusion of their investigation was that of “a trend of febrile and respiratory illness that progresses to death within one to two weeks. These deaths occurred in various localities in Kano and are predominantly amongst elderly people with underlying medical conditions. This presentation mirrors severe COVID-19 cases reported around the world.” And they explained: “One of the contacts, who had lost a father, stated that he became ill about one week after (attending) a wedding ceremony. He had fever, shortness of breath and diarrhea. Attempts to contact the Nigerian Centre for Disease Control (NCDC) were unsuccessful and he passed away a week later. Another contact stated that the deceased had fever and shortness of breath for a week. He was initially treated for pneumonia at a private hospital and subsequently required a ventilator. There were several reports of multiple people in a household or in a neighborhood dying from similar illness. Of note, 40 out of 51 deaths had no recent travel history.”

While we await the outcome of the official verbal autopsy, the report of the medical doctors corroborates that of others, including the one by Yusuf Yau Gambo of Yusuf Maitama Bello University, Kano. Dated 28th April, 2020 (Tuesday), the ‘community-based survey’ report (reviewed by Auwal Abubakar, a medical and health professional with the University of California Berkeley and Audu Liman, Chief of Party, USAID SENSE Project, American University of Nigeria) indicates that given the symptoms exhibited by the deceased, the incubation period of their illnesses as well as the age group involved, “the possibility of relating the situation to the current COVID-19 pandemic could not be ruled out”. Meanwhile, Maryam Nasir, Zainab Mahmoud and Khadija Rufai made far–reaching recommendations. These include enhancing testing capacity and community-based testing; establishing mobile testing centers within the city; providing personal protective equipment (PPE) to all staff with potential exposures especially at points of initial patient contact; recognising the consequences of neglected non-COVID-19 medical care and imposing strict guidelines for burials.

From respected clerics to eminent scholars and medical practitioners, I have read many interventions by Kano stakeholders on the mismanagement of COVID-19 by Ganduje and the urgent need for President Buhari to take personal responsibility for the state. Many politicians, including former Governor Rabiu Musa Kwankwaso have also weighed in. Calling on the president to declare a state of emergency in Kano, Dr Mukhtar Datti Ahmed said he cannot imagine a graver situation than what is happening in the state today. “21 years of personalised government and denudation of the civil service and civil structures have joined forces with Covid-19 in wreaking disaster among our people”, he wrote. He added that although Lagos was given 10 billion to aid its fight against COVID-19, “I fear the mind-set of the current government (in Kano) would render any grants as good as water down the drain. There simply isn’t a credible plan or a coalition of experts to make the best use of any funds provided.”

As much as I believe Ganduje has mismanaged the crisis, I worry that politicising the tragedy will not serve the interests of Kano people. President Buhari must get the governor to work with political, traditional and religious authorities in the state. Ganduje must also be made to understand that when you have a complex problem, raw measures don’t help. He must follow the advice of experts and invest in soft skills such as surveillance and laboratory systems. Ganduje should also quickly put together a media team that will embark on risk communication in Kano State. And he must work with all federal agencies, private individuals and development partners that may want to help in dealing with this challenge.

But beyond the Kano debacle, there are more challenges ahead as the COVID-19 pandemic ravages the entire country. From Monday, restrictions placed on residents of Lagos and Ogun states as well as those in Abuja will be lifted. With that, we are embarking on the Swedish option of taking personal preventive measures, and ultimately hoping for a measure of ‘Herd immunity’. This happens after infections have resulted in the deaths of many (hopefully not too many) and the recovery of others. Lifting the lockdown was predicated on the reality that daily survival has become too difficult for our citizens. However, this also comes with a cost, especially in our kind of environment. That will become clear in the days, weeks, and possibly months ahead.

If we are to win the war against COVID-19, there are several things that should happen. One, we have to destigmatise both the reportage and the manner in which infected people are being viewed by society. When people begin to hide what ails them as a result of stigma or run away from isolation centres as has happened in some states, they endanger themselves, their families and the rest of us, especially as we enter a new phase in the battle against the virus. Two, there is an urgent need for the president to host a meeting (even if virtual) with the governors so they can all be on the same page in this fight. Right now, they are pulling in different directions. Three, it is important to streamline activities of the presidential task force. As to be expected of such a body with nine ministers, I understand the task force has become dysfunctional. What we need is a command and control system that will place the federal ministry of health and the NCDC at the centre of efforts to tackle the pandemic. The present arrangement is not working.

However, this pandemic also comes with opportunities to reinvent our country. For instance, contact tracing has been difficult because there are no credible records to work with. If we are to build an economy based on the productive capacity of our people as opposed to sharing dwindling oil money, there are salient questions we must address. How many Nigerians are we? Where do we live? How many are unemployed? How many tax payers do we have? What are the age demographics of our citizens? These and several other questions are hanging in the air. If we are serious, one of the first things we should do after this COVID-19 scourge is to begin the process of a biometric-driven population census. We must stop running our country on the basis of assumptions.

The next issue, of course, has to do with the health care delivery system in the country. COVID-19 has exposed our nakedness. Even the affluent have no place to run. In posing the question, ‘Can Africa really afford lockdowns, and can they be effective?’ and whether people on the continent can successfully and sustainably defeat COVID-19 by copying the template of Western nations in his well circulated paper, former CBN Governor, Prof Chukwuma Soludo advocated the trial of local herbs. “While the U.K. and others are experimenting with vaccines, you never know if an Africa herb might be the cure. Necessity is the mother of invention, and only those who dare, succeed!” he wrote.

Aside his brilliant economic prognosis, I like Soludo’s proposition on local herbs which has been tried by other countries. According to China’s National Health Commission, about 90 percent of their nationals infected with COVID-19 took some form of traditional Chinese medicine to treat their symptoms. These traditional remedies, according to the commission, helped to alleviate symptoms, reduced the severity of the virus, improved recovery and reduced mortality rate. Growing up in the village where you took these concoctions every morning, some of us are well aware of the efficacy of herbs, even though we have not developed them as other societies have. Perhaps this is the time to commence efforts in that direction.

It is regrettable that the federal government has not challenged our universities and research institutions to find a workable testing regime and vaccine. For a country that boasts some of the best experts in most fields, based both at home and abroad, government funding should be channeled towards enabling our national scientific efforts to be part of a lasting solution. Rather than asking the president to allow them to “import a plane load” of herbs from Madagascar for a trial on COVID-19 as the secretary to the government of the federation (SGF), Mr Boss Mustapha is suggesting, we should look inwards. This is not a time for frivolity. Now that we are easing up from Monday, what can we do individually and collectively, given our realities, to prevent an explosion? What is the responsibility of thought leaders, employers, and governments? What is the place of individual responsibility? Have we engaged our clerics enough, give the influence they hold over their members? Those are the issues that should concern Boss Mustapha and his presidential task force.

While the health system in our country is weak, a product of decisions taken over decades, even the best health systems in the world have not come out smelling of roses in their encounter with COVID-19. The number one lesson when dealing with a pandemic is the quality of response matters more. All factors considered, we have not done too badly in that area even when there is room for improvement. The greater challenge is how not to waste this crisis. We must learn appropriate lessons to improve our health system and build a more resilient economy for the post-coronavirus world.